Healthcare Provider Details

I. General information

NPI: 1659182624
Provider Name (Legal Business Name): JUDY FERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 SUNLIGHT HILL ST
HENDERSON NV
89011-5402
US

IV. Provider business mailing address

645 SUNLIGHT HILL ST
HENDERSON NV
89011-5402
US

V. Phone/Fax

Practice location:
  • Phone: 702-985-7088
  • Fax:
Mailing address:
  • Phone: 702-985-7088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN73725
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: