Healthcare Provider Details

I. General information

NPI: 1164062691
Provider Name (Legal Business Name): MARINA HERNANDEZ HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 SKY FLOWER LN
SAINT CLOUD FL
34772-8842
US

IV. Provider business mailing address

4207 SKY FLOWER LN
SAINT CLOUD FL
34772-8842
US

V. Phone/Fax

Practice location:
  • Phone: 786-282-2588
  • Fax:
Mailing address:
  • Phone: 786-282-2588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-22-13891
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: