Provider Demographics
NPI:1700586799
Name:SANTIESTEBAN HERNANDEZ, MIDALYS
Entity Type:Individual
Prefix:
First Name:MIDALYS
Middle Name:
Last Name:SANTIESTEBAN 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 1:10023 BELLE RIVE BLVD APT 1304
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9580
Mailing Address - Country:US
Mailing Address - Phone:305-497-9861
Mailing Address - Fax:
Practice Address - Street 1:10023 BELLE RIVE BLVD APT 1304
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9580
Practice Address - Country:US
Practice Address - Phone:305-497-9861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLS532540869500106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty