Healthcare Provider Details

I. General information

NPI: 1588083349
Provider Name (Legal Business Name): MARY HERNANDEZ NUTRITIONIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 UNIVERSITY PL
STATEN ISLAND NY
10301-3423
US

IV. Provider business mailing address

185 BEMENT AVE
STATEN ISLAND NY
10310-1505
US

V. Phone/Fax

Practice location:
  • Phone: 718-442-2577
  • Fax:
Mailing address:
  • Phone: 718-442-2577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: