Provider Demographics
NPI:1265309298
Name:FERNANDEZ, LISSET CAROLINA
Entity type:Individual
Prefix:
First Name:LISSET
Middle Name:CAROLINA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83766 AVENIDA VERANO
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-5504
Mailing Address - Country:US
Mailing Address - Phone:760-541-9560
Mailing Address - Fax:
Practice Address - Street 1:2500 N PALM CANYON DR STE A4
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-1866
Practice Address - Country:US
Practice Address - Phone:442-268-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-23
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALVNSTUDENT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty