Healthcare Provider Details

I. General information

NPI: 1518011410
Provider Name (Legal Business Name): LORI MARIE FERNANDEZ RD,CNSD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 KIELY BLVD
SANTA CLARA CA
95051-5329
US

IV. Provider business mailing address

900 KIELY BLVD
SANTA CLARA CA
95051-5329
US

V. Phone/Fax

Practice location:
  • Phone: 408-236-4257
  • Fax: 408-236-4973
Mailing address:
  • Phone: 408-236-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: