Healthcare Provider Details

I. General information

NPI: 1235727330
Provider Name (Legal Business Name): WALTER FERNANDEZ RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: WALTER FERNANDEZ RN

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203
US

IV. Provider business mailing address

10241 CULPEPPER CT
HARRISBURG NC
28075
US

V. Phone/Fax

Practice location:
  • Phone: 704-719-0369
  • Fax:
Mailing address:
  • Phone: 704-719-0369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number288725
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: