Provider Demographics
NPI:1043618804
Name:FERNANDEZ, WIGSAURY M
Entity type:Individual
Prefix:
First Name:WIGSAURY
Middle Name:M
Last Name:FERNANDEZ
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 1:2301 RAMA RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-6237
Mailing Address - Country:US
Mailing Address - Phone:704-563-4322
Mailing Address - Fax:
Practice Address - Street 1:2301 RAMA RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-6237
Practice Address - Country:US
Practice Address - Phone:704-563-4322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJP0092201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical