Provider Demographics
NPI:1063877207
Name:FERNANDEZ, KENNETH
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 COMLY RD
Mailing Address - Street 2:M13
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035
Mailing Address - Country:US
Mailing Address - Phone:973-572-2940
Mailing Address - Fax:
Practice Address - Street 1:209 COMLY RD
Practice Address - Street 2:M13
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035
Practice Address - Country:US
Practice Address - Phone:973-572-2940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09114900224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant