Provider Demographics
NPI:1154342590
Name:FERNANDEZ, LEONIDAS (CDN)
Entity type:Individual
Prefix:MS
First Name:LEONIDAS
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14809 88TH AVE APT 3A
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-3424
Mailing Address - Country:US
Mailing Address - Phone:718-297-0220
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004194133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7R8231Medicare ID - Type Unspecified
NYP61922Medicare UPIN