Basic Information
| Provider Information | |||||||||
| NPI: | 1891094512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDES | ||||||||
| FirstName: | KANAN | ||||||||
| MiddleName: | DOMINICA LUCY | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13629 PALMETTO CIR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208746234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015282016 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7600 CARROLL AVE | ||||||||
| Address2: | |||||||||
| City: | TAKOMA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209126367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018917600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2011 | ||||||||
| LastUpdateDate: | 03/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | R164021 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | R164021 | 01 | MD | MARYLAND BOARD OF NURSING- CRNP LICENSE NUMBER | OTHER |