Healthcare Provider Details

I. General information

NPI: 1649660028
Provider Name (Legal Business Name): INGRID J HERNANDEZ RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 AVE AVELINO VICENTE
SAN JUAN PR
00909-2538
US

IV. Provider business mailing address

URBANIZACION MATIENZO CINTRON C/SOLLER #520
SAN JUAN PR
00923-2116
US

V. Phone/Fax

Practice location:
  • Phone: 787-303-9662
  • Fax: 787-724-5559
Mailing address:
  • Phone: 787-246-1443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2077
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: