Provider Demographics
NPI:1356034797
Name:FERNANDEZ, PENELOPE NOEMI
Entity type:Individual
Prefix:
First Name:PENELOPE
Middle Name:NOEMI
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 1:18480 NW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-3823
Mailing Address - Country:US
Mailing Address - Phone:786-376-5812
Mailing Address - Fax:
Practice Address - Street 1:18480 NW 19TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-3823
Practice Address - Country:US
Practice Address - Phone:786-376-5812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician