Provider Demographics
NPI:1821557315
Name:HERNANDEZ, WENDY LICET (PTA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:LICET
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:LICET
Other - Last Name:NIEVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:211 ESPLANADE WAY APT 107
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-6816
Mailing Address - Country:US
Mailing Address - Phone:321-295-1640
Mailing Address - Fax:
Practice Address - Street 1:215 ANNIE ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1207
Practice Address - Country:US
Practice Address - Phone:407-847-4371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28806225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant