MEDICARE: BRENDA KARINA FUENTES CUELLAR

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	104100000X	Social Worker		NE

General Provider Information

NPI Number	:	1770296238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA KARINA FUENTES CUELLAR

Provider Business Mailing Address
First Line	:	2415 DOVER DR
Second Line	:
City	:	NORFOLK
State	:	NE
Zip	:	68701-2017
Country	:	US
Telephone Number	:	402-302-4116
Fax Number	:

Provider Business Practice Location Address
First Line	:	2415 DOVER DR
Second Line	:
City	:	NORFOLK
State	:	NE
Zip	:	68701-2017
Country	:	US
Telephone Number	:	402-302-4116
Fax Number	:

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

Provider Enumeration Date	:	12/29/2022
Last Update Date	:	12/29/2022

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