1790108868 NPI number — MRS. LESLIE P FERNANDEZ CRNA

Table of content: MRS. LESLIE P FERNANDEZ CRNA (NPI 1790108868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790108868 NPI number — MRS. LESLIE P FERNANDEZ CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ
Provider First Name:
LESLIE
Provider Middle Name:
P
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRIEDBERG
Provider Other First Name:
LESLIE
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790108868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 551420
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33355-1420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-243-3839
Provider Business Mailing Address Fax Number:
855-851-4405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4725 N. FEDERAL HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-4603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-493-5005
Provider Business Practice Location Address Fax Number:
954-938-0957
Provider Enumeration Date:
01/27/2014

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: 367500000X , with the licence number:  ARNP9276746 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010654900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104214700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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