MEDICARE: STACY ANN HARRIS HERNANDEZ FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024186270	VA

General Provider Information

NPI Number	:	1215434253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY ANN HARRIS HERNANDEZ FNP-BC

Provider Business Mailing Address
First Line	:	801 YORK ST
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54220-4630
Country	:	US
Telephone Number	:	920-663-9008
Fax Number	:	920-684-1439

Provider Business Practice Location Address
First Line	:	2206 EXECUTIVE DR STE F
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-2583
Country	:	US
Telephone Number	:	757-825-1440
Fax Number	:	757-825-1587

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2018
Last Update Date	:	09/16/2024

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