1629574330 NPI number — MS. CARMEN YADIRA FENOLLAL GONZALEZ

Table of content: MS. CARMEN YADIRA FENOLLAL GONZALEZ (NPI 1629574330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629574330 NPI number — MS. CARMEN YADIRA FENOLLAL GONZALEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FENOLLAL GONZALEZ
Provider First Name:
CARMEN
Provider Middle Name:
YADIRA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FENOLLAL GONZALEZ
Provider Other First Name:
CARMEN
Provider Other Middle Name:
YADIRA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1629574330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9050 NW 28TH ST APT 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAL SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33065-5213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-398-7614
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9050 NW 28TH ST APT 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORAL SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33065-5213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
130-576-7810
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2018

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: 376J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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