Provider Demographics
NPI:1265998801
Name:CHACON HERNANDEZ, LOURDES
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:CHACON 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 1:6516 MIAMI LAKES DR E
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2755
Mailing Address - Country:US
Mailing Address - Phone:305-812-5922
Mailing Address - Fax:
Practice Address - Street 1:14000 NW 41ST ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-3003
Practice Address - Country:US
Practice Address - Phone:305-717-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-70812106S00000X
FLRN9551811163W00000X
FLAPRN11024442363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No163W00000XNursing Service ProvidersRegistered Nurse