Basic Information
| Provider Information | |||||||||
| NPI: | 1124533138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | CAITLIN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAYLOR | ||||||||
| OtherFirstName: | CAITLIN | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 114 UNIVERSITY AVE | ||||||||
| Address2: | ATTN CREDENTIALING | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146056626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855462771 | ||||||||
| FaxNumber: | 3152227435 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 UNIVERSITY AVE | ||||||||
| Address2: | ATTN CREDENTIALING | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146056626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855462771 | ||||||||
| FaxNumber: | 3152227435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2017 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP018683 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | F348628-01 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 06742736 | 05 | NY | MEDICAID |