Provider Demographics
NPI:1790156859
Name:HERNANDEZ, LATICIA
Entity Type:Individual
Prefix:
First Name:LATICIA
Middle Name:
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 1:3139 ELECTRIC AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-8103
Mailing Address - Country:US
Mailing Address - Phone:810-990-9312
Mailing Address - Fax:
Practice Address - Street 1:3139 ELECTRIC AVE APT 3
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8103
Practice Address - Country:US
Practice Address - Phone:810-990-9312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIH 655 488 785 108172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI86663636Medicaid