Provider Demographics
NPI:1962762153
Name:FERNANDES, KIM LEE
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:LEE
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:PO BOX 1083
Mailing Address - Street 2:
Mailing Address - City:OSTERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02655-5083
Mailing Address - Country:US
Mailing Address - Phone:508-790-0606
Mailing Address - Fax:
Practice Address - Street 1:540 MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5100
Practice Address - Country:US
Practice Address - Phone:508-694-6598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA777225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist