Basic Information
Provider Information
NPI: 1003297698
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FERNANDEZ
FirstName: SANDRA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: B.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4180 S PECOS RD
Address2:  
City: LAS VEGAS
State: NV
PostalCode: 891215074
CountryCode: US
TelephoneNumber: 7024867581
FaxNumber: 7024867576
Practice Location
Address1: 4180 S PECOS RD
Address2:  
City: LAS VEGAS
State: NV
PostalCode: 891215074
CountryCode: US
TelephoneNumber: 7024867581
FaxNumber: 7024867576
Other Information
ProviderEnumerationDate: 06/09/2015
LastUpdateDate: 06/09/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171M00000X NVY Other Service ProvidersCase Manager/Care Coordinator 

No ID Information.


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