Healthcare Provider Details

I. General information

NPI: 1699534214
Provider Name (Legal Business Name): YILIAN FERNANDEZ LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 03/18/2024
Certification Date: 03/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 NE 24TH AVE
CAPE CORAL FL
33909-2807
US

IV. Provider business mailing address

317 NE 24TH AVE
CAPE CORAL FL
33909-2807
US

V. Phone/Fax

Practice location:
  • Phone: 786-348-3428
  • Fax:
Mailing address:
  • Phone: 786-348-3428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-330689
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: