Provider Demographics
NPI:1093956237
Name:RENGIFO-CAICEDO, FERNANDO (SLP007041)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:RENGIFO-CAICEDO
Suffix:
Gender:M
Credentials:SLP007041
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 RED HART LN
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-4142
Mailing Address - Country:US
Mailing Address - Phone:202-297-5314
Mailing Address - Fax:
Practice Address - Street 1:856 RED HART LN
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-4142
Practice Address - Country:US
Practice Address - Phone:202-297-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-18
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007041235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1331465OtherDRIVER'S LICENSE