Healthcare Provider Details

I. General information

NPI: 1316082886
Provider Name (Legal Business Name): LIDETTE REBECCA FERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6447 MIAMI LAKES DR SUITE 105
MIAMI LAKES FL
33014-2741
US

IV. Provider business mailing address

7474 NW 167TH TER
HIALEAH FL
33015-4151
US

V. Phone/Fax

Practice location:
  • Phone: 786-365-4834
  • Fax:
Mailing address:
  • Phone: 305-965-5465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number3958
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: