Healthcare Provider Details

I. General information

NPI: 1053054072
Provider Name (Legal Business Name): OTTONIEL HERNANDEZ NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62ND AVE STE 124
MIAMI FL
33155-3009
US

IV. Provider business mailing address

3100 SW 62ND AVE STE 124
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 305-662-8316
  • Fax: 305-663-8513
Mailing address:
  • Phone: 305-662-8316
  • Fax: 305-663-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11018958
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: