Provider Demographics
NPI:1841366432
Name:FERNANDEZ, MARY JANE (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16317 BAWTY CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715
Mailing Address - Country:US
Mailing Address - Phone:301-464-2581
Mailing Address - Fax:301-464-1824
Practice Address - Street 1:4351 NORTHVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-2602
Practice Address - Country:US
Practice Address - Phone:301-464-1893
Practice Address - Fax:301-464-1824
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S891 0001OtherCAREFIRST
MD512984 01OtherCAREFIRST
00B704B34Medicare ID - Type Unspecified