Provider Demographics
NPI:1104346931
Name:FERNANDEZ, IVANN
Entity type:Individual
Prefix:
First Name:IVANN
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 1:8700 ELFIN CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-6796
Mailing Address - Country:US
Mailing Address - Phone:916-513-0256
Mailing Address - Fax:
Practice Address - Street 1:8700 ELFIN CT
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-6796
Practice Address - Country:US
Practice Address - Phone:916-513-0256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician