Healthcare Provider Details

I. General information

NPI: 1679095350
Provider Name (Legal Business Name): JEAN RHADENIE HERNANDEZ MONTES FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 E SOUTH ST STE 305
LAKEWOOD CA
90805-4595
US

IV. Provider business mailing address

1580 SANTA BARBARA BLVD
THE VILLAGES FL
32159-6827
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 352-259-2159
  • Fax: 352-259-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number95005912
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberAPRN11016885
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11016885
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: