=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831680263
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERNESTO JOSE FERNANDEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2018
-----------------------------------------------------
Last Update Date | 06/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 CONDUCTOR LN APT 720
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28115-5419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-673-2320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 LEONARD AVE
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28658-9649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-464-8260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 14082
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------