Provider Demographics
NPI:1134690068
Name:HERNANDEZ MACEDA, LEIDYS
Entity Type:Individual
Prefix:
First Name:LEIDYS
Middle Name:
Last Name:HERNANDEZ MACEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6229 OLD TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-2530
Mailing Address - Country:US
Mailing Address - Phone:702-986-1640
Mailing Address - Fax:
Practice Address - Street 1:6229 OLD TRAIL RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-2530
Practice Address - Country:US
Practice Address - Phone:702-986-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV11852957483OtherDL