Provider Demographics
NPI:1205163714
Name:HERNANDEZ, MABEL
Entity type:Individual
Prefix:
First Name:MABEL
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 1:7737 N UNIVERSITY DR STE 107
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2968
Mailing Address - Country:US
Mailing Address - Phone:954-720-0056
Mailing Address - Fax:
Practice Address - Street 1:7737 N UNIVERSITY DR STE 107
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2968
Practice Address - Country:US
Practice Address - Phone:954-720-0056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49255174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051555800Medicaid
FLF10417Medicare UPIN