Provider Demographics
NPI:1326721663
Name:HERNANDEZ POLANCO, LORRAINE BEATRIZ
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:BEATRIZ
Last Name:HERNANDEZ POLANCO
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 1:4675 W 18TH CT APT 405
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2842
Mailing Address - Country:US
Mailing Address - Phone:786-890-9915
Mailing Address - Fax:
Practice Address - Street 1:4675 W 18TH CT APT 405
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2842
Practice Address - Country:US
Practice Address - Phone:786-890-9915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23-497363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical