=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912545245
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER FERNANDEZ MOTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2019
-----------------------------------------------------
Last Update Date | 12/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 S DURBIN ST STE 105
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82601-7031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-389-9867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1406 CUSTER AVE
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82604-3138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-389-9867
-----------------------------------------------------
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 | OT-1420
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------