=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356527428
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH HERNANDEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2008
-----------------------------------------------------
Last Update Date | 01/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 SHAMROCK LN
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06850-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-354-3968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 SHAMROCK LN
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06850-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-354-3968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 290749
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------