1679631998 NPI number — MRS. SHANNA LYN FERNANDEZ LMSW

Table of content: MRS. SHANNA LYN FERNANDEZ LMSW (NPI 1679631998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679631998 NPI number — MRS. SHANNA LYN FERNANDEZ LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ
Provider First Name:
SHANNA
Provider Middle Name:
LYN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEINBERG
Provider Other First Name:
SHANNA
Provider Other Middle Name:
LYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679631998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
490 RIDGE RD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14621-1229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-922-2500
Provider Business Mailing Address Fax Number:
585-922-2664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
490 RIDGE RD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14621-1229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-922-2500
Provider Business Practice Location Address Fax Number:
585-922-2664
Provider Enumeration Date:
12/06/2006

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: 104100000X , with the licence number:  068610 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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