Provider Demographics
NPI:1699421198
Name:FERNANDES, LIESL
Entity type:Individual
Prefix:
First Name:LIESL
Middle Name:
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2453 VIVIAN CIR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1592
Mailing Address - Country:US
Mailing Address - Phone:201-218-5146
Mailing Address - Fax:
Practice Address - Street 1:2453 VIVIAN CIR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1592
Practice Address - Country:US
Practice Address - Phone:201-218-5146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator