MEDICARE: DR. DIANNE MICHELLE FERNANDEZ D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH0005777	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	39666	OTHER	FL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1104975739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANNE MICHELLE FERNANDEZ D.C.

Provider Business Mailing Address
First Line	:	421 48TH AVE N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33703-3824
Country	:	US
Telephone Number	:	727-527-6095
Fax Number	:

Provider Business Practice Location Address
First Line	:	4800 4TH ST N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33703-3817
Country	:	US
Telephone Number	:	727-528-1133
Fax Number	:	727-527-3750

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	07/08/2007

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