Provider Demographics
NPI:1780072496
Name:FERNANDEZ, ANA MARIA
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:MARIA
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 1:39 CHAMPLAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-4432
Mailing Address - Country:US
Mailing Address - Phone:631-889-5948
Mailing Address - Fax:
Practice Address - Street 1:39 CHAMPLAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-4432
Practice Address - Country:US
Practice Address - Phone:631-889-5948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-03
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320225164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse