MEDICARE: NICOLE 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	235Z00000X	Speech-Language Pathologist	SZ6829	FL

General Provider Information

NPI Number	:	1366842700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE FERNANDEZ

Provider Business Mailing Address
First Line	:	6405 NW 36TH ST STE 105
Second Line	:
City	:	VIRGINIA GARDENS
State	:	FL
Zip	:	33166-6977
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6405 NW 36TH ST STE 105
Second Line	:
City	:	VIRGINIA GARDENS
State	:	FL
Zip	:	33166-6977
Country	:	US
Telephone Number	:	305-526-2426
Fax Number	:

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

Provider Enumeration Date	:	09/03/2014
Last Update Date	:	09/03/2014

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Directions to “ NICOLE FERNANDEZ ” Practice Location

Language	Start Address	Practice Location

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