Provider Demographics
NPI:1770753667
Name:FERNANDES, DIANA LISA (LIC AC, MAOM)
Entity type:Individual
Prefix:MISS
First Name:DIANA
Middle Name:LISA
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:LIC AC, MAOM
Other - Prefix:
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Mailing Address - Street 1:277 MAIN ST STE 208
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-5521
Mailing Address - Country:US
Mailing Address - Phone:978-473-9393
Mailing Address - Fax:978-568-0767
Practice Address - Street 1:277 MAIN ST STE 208
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-5521
Practice Address - Country:US
Practice Address - Phone:978-473-9393
Practice Address - Fax:978-568-0767
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA233902171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist