Provider Demographics
NPI:1790191591
Name:HERNANDEZ, JAMIE LYN (LPN)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYN
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4744 CR 542H
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-5558
Mailing Address - Country:US
Mailing Address - Phone:772-321-6276
Mailing Address - Fax:
Practice Address - Street 1:4744 CR 542H
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-5558
Practice Address - Country:US
Practice Address - Phone:772-321-6276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL60-44-1546773246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical