Healthcare Provider Details

I. General information

NPI: 1396426664
Provider Name (Legal Business Name): AIMEE FERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 GRAND AVE
WAUKEGAN IL
60085-2321
US

IV. Provider business mailing address

3010 GRAND AVE
WAUKEGAN IL
60085-2321
US

V. Phone/Fax

Practice location:
  • Phone: 847-377-8085
  • Fax: 847-984-5685
Mailing address:
  • Phone: 847-377-8085
  • Fax: 847-984-5685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041461061
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: