Provider Demographics
NPI:1689173171
Name:HERNANDEZ, MIA ROSE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MIA
Middle Name:ROSE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:ROSE
Other - Last Name:SIMONCELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:3050 ORCHARD PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224
Mailing Address - Country:US
Mailing Address - Phone:716-675-5222
Mailing Address - Fax:
Practice Address - Street 1:3050 ORCHARD PARK RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224
Practice Address - Country:US
Practice Address - Phone:716-675-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF342490-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily