Healthcare Provider Details

I. General information

NPI: 1760949093
Provider Name (Legal Business Name): MONA LISA FERNANDEZ RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 W YOSEMITE AVE
MANTECA CA
95337-5130
US

IV. Provider business mailing address

1208 ATHENS AVE
MODESTO CA
95350-3410
US

V. Phone/Fax

Practice location:
  • Phone: 209-825-3700
  • Fax:
Mailing address:
  • Phone: 209-214-4536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number20998
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: