Provider Demographics
NPI:1245793769
Name:OLIVERAS HERNANDEZ, LYDMARIE (LND)
Entity Type:Individual
Prefix:MRS
First Name:LYDMARIE
Middle Name:
Last Name:OLIVERAS HERNANDEZ
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2218
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-2218
Mailing Address - Country:US
Mailing Address - Phone:787-532-8785
Mailing Address - Fax:
Practice Address - Street 1:B11 CALLE SANTA CRUZ
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-6902
Practice Address - Country:US
Practice Address - Phone:787-314-6825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1973133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5260OtherMCS
PR5260Medicaid