Provider Demographics
NPI:1558850438
Name:FERRERA, YACIEL FERNANDO
Entity type:Individual
Prefix:
First Name:YACIEL
Middle Name:FERNANDO
Last Name:FERRERA
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 1:225 S PLUMOSA ST
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3525
Mailing Address - Country:US
Mailing Address - Phone:321-452-6000
Mailing Address - Fax:
Practice Address - Street 1:225 S PLUMOSA ST
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3525
Practice Address - Country:US
Practice Address - Phone:321-452-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-06
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23755122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist