MEDICARE: SHALISE FERNANDER

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	101Y00000X	Counselor

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	:	1912644162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHALISE FERNANDER

Provider Business Mailing Address
First Line	:	1330 W AUTO DR
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85284-1017
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1330 W AUTO DR
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85284-1017
Country	:	US
Telephone Number	:	480-553-7153
Fax Number	:

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

Provider Enumeration Date	:	05/18/2022
Last Update Date	:	05/18/2022

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Directions to “ SHALISE FERNANDER ” Practice Location

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