Provider Demographics
NPI:1467107961
Name:HERNANDEZ, LESLIE D
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:D
Last Name:HERNANDEZ
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 1:3624 SENECA CLUB LOOP UNIT B
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-3182
Mailing Address - Country:US
Mailing Address - Phone:140-745-0501
Mailing Address - Fax:
Practice Address - Street 1:3624 SENECA CLUB LOOP UNIT B
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-3182
Practice Address - Country:US
Practice Address - Phone:321-961-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLH655524729570172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver