Basic Information
| Provider Information | |||||||||
| NPI: | 1144297516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDEZ KIEMELE | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | CASTRO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FERNANDEZ | ||||||||
| OtherFirstName: | MARISSA | ||||||||
| OtherMiddleName: | CASTRO | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7 HOLLAND WAY FL 1 | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038332997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039291195 | ||||||||
| FaxNumber: | 6039291196 | ||||||||
| Practice Location | |||||||||
| Address1: | 879 LAFAYETTE RD | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039291195 | ||||||||
| FaxNumber: | 6039291196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 18726 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3112129 | 05 | NH | MEDICAID |