Healthcare Provider Details

I. General information

NPI: 1326721663
Provider Name (Legal Business Name): LORRAINE BEATRIZ HERNANDEZ POLANCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/14/2023
Certification Date: 06/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4675 W 18TH CT APT 405
HIALEAH FL
33012-2842
US

IV. Provider business mailing address

4675 W 18TH CT APT 405
HIALEAH FL
33012-2842
US

V. Phone/Fax

Practice location:
  • Phone: 786-890-9915
  • Fax:
Mailing address:
  • Phone: 786-890-9915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number23-497
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: