MEDICARE: KATELYN ALYSSA HERNANDEZ MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1932667623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN ALYSSA HERNANDEZ MS

Provider Business Mailing Address
First Line	:	510 SE 5TH AVE APT 1108
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2998
Country	:	US
Telephone Number	:	818-657-9123
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 SE 5TH AVE APT 1108
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2998
Country	:	US
Telephone Number	:	818-657-9123
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2019
Last Update Date	:	03/12/2019

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