Provider Demographics
NPI:1750924692
Name:HERNANDO, MICHELLE LYNN (IDMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:HERNANDO
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:DYESS AFB
Mailing Address - State:TX
Mailing Address - Zip Code:79607-1007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:DYESS AFB
Practice Address - State:TX
Practice Address - Zip Code:79607-1007
Practice Address - Country:US
Practice Address - Phone:325-513-2435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians