Provider Demographics
NPI:1659492932
Name:HERNANDEZ, MILDRED (DIETICIAN)
Entity Type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 CALLE HUMACAO
Mailing Address - Street 2:STOP 20
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00909-2633
Mailing Address - Country:US
Mailing Address - Phone:787-722-4564
Mailing Address - Fax:787-771-7951
Practice Address - Street 1:1715 AVE PONCE DE LEON
Practice Address - Street 2:NUTRITION DEPT.
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-1958
Practice Address - Country:US
Practice Address - Phone:787-758-2000
Practice Address - Fax:787-771-7951
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR645132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR645OtherDIETICIAN'S LICENSE