MEDICARE: NICHOLAS RAPHAEL FERNANDEZ

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1245098409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS RAPHAEL FERNANDEZ

Provider Business Mailing Address
First Line	:	12217 BUSHEY DR
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20902-1014
Country	:	US
Telephone Number	:	301-887-7321
Fax Number	:

Provider Business Practice Location Address
First Line	:	12217 BUSHEY DR
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20902-1014
Country	:	US
Telephone Number	:	301-887-7321
Fax Number	:

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

Provider Enumeration Date	:	03/11/2024
Last Update Date	:	03/11/2024

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