MEDICARE: FERNANDA SA

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	367500000X	Certified Registered Nurse Anesthetist	11005539	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861036782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FERNANDA SA

Provider Business Mailing Address
First Line	:	5110 S MANHATTAN AVE UNIT 2306
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-3444
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5110 S MANHATTAN AVE UNIT 2306
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-3444
Country	:	US
Telephone Number	:	954-871-8779
Fax Number	:

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

Provider Enumeration Date	:	11/04/2019
Last Update Date	:	02/21/2020

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Directions to “ FERNANDA SA ” Practice Location

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