1588071138 NPI number — FERNANDA MARIEL AGUILERA LICENTIATE

Table of content: FERNANDA MARIEL AGUILERA LICENTIATE (NPI 1588071138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588071138 NPI number — FERNANDA MARIEL AGUILERA LICENTIATE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGUILERA
Provider First Name:
FERNANDA
Provider Middle Name:
MARIEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICENTIATE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588071138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7512 HEATHERTON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTOMAC
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20854-3231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-431-0370
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9801 GEORGIA AVE
Provider Second Line Business Practice Location Address:
SUITE 229
Provider Business Practice Location Address City Name:
SILVER SPRING
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20902-5276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-754-2200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2355S0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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