Healthcare Provider Details

I. General information

NPI: 1649602863
Provider Name (Legal Business Name): AMANDA J. FERNANDES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WAMPANOAG TRL
RIVERSIDE RI
02915
US

IV. Provider business mailing address

110 ELM ST FL 2
PROVIDENCE RI
02903-4626
US

V. Phone/Fax

Practice location:
  • Phone: 401-649-4090
  • Fax:
Mailing address:
  • Phone: 401-443-4992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD16760
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: