MEDICARE: MS. LISSETTE HERNANDEZ M.S.

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	174400000X	Specialist	543982041	NY

General Provider Information

NPI Number	:	1447514088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISSETTE HERNANDEZ M.S.

Provider Business Mailing Address
First Line	:	3250 B'WAY
Second Line	:	APT. 13 J
City	:	NEW YORK
State	:	NY
Zip	:	10027
Country	:	US
Telephone Number	:	845-596-4042
Fax Number	:

Provider Business Practice Location Address
First Line	:	3250 B'WAY
Second Line	:	APT. 13 J
City	:	NEW YORK
State	:	NY
Zip	:	10027
Country	:	US
Telephone Number	:	845-596-4042
Fax Number	:

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

Provider Enumeration Date	:	06/28/2012
Last Update Date	:	06/28/2012

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