Provider Demographics
NPI:1528693777
Name:HERNANDEZ, DENISE (PTA)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12208 SW 251ST TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5925
Mailing Address - Country:US
Mailing Address - Phone:786-302-7514
Mailing Address - Fax:
Practice Address - Street 1:311 NE 8TH ST STE 104
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4734
Practice Address - Country:US
Practice Address - Phone:305-248-8600
Practice Address - Fax:844-272-8151
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30112225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA30112Medicaid