Provider Demographics
NPI:1720817992
Name:FERNANDO, MINDY
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:FERNANDO
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 1:27256 APPLE TREE LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025
Mailing Address - Country:US
Mailing Address - Phone:248-914-8901
Mailing Address - Fax:
Practice Address - Street 1:1266 WALTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6900
Practice Address - Country:US
Practice Address - Phone:248-710-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47044322761363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily