Healthcare Provider Details

I. General information

NPI: 1245446640
Provider Name (Legal Business Name): CARLEEN MAE GAYO FERNANDEZ CARLEEN FERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11375 PONDHURST WAY
RIVERSIDE CA
92505-3471
US

IV. Provider business mailing address

11375 PONDHURST WAY
RIVERSIDE CA
92505
US

V. Phone/Fax

Practice location:
  • Phone: 951-522-1205
  • Fax:
Mailing address:
  • Phone: 951-522-1205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 8102
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: