Healthcare Provider Details

I. General information

NPI: 1245793769
Provider Name (Legal Business Name): LYDMARIE OLIVERAS HERNANDEZ LND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

B11 CALLE SANTA CRUZ
BAYAMON PR
00961-6902
US

IV. Provider business mailing address

PO BOX 2218
VEGA BAJA PR
00694-2218
US

V. Phone/Fax

Practice location:
  • Phone: 787-314-6825
  • Fax:
Mailing address:
  • Phone: 787-532-8785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1973
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: