Provider Demographics
NPI:1730619784
Name:HERNANDEZ HERNANDEZ, ANTONIO
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:HERNANDEZ HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 SW 89TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-2338
Mailing Address - Country:US
Mailing Address - Phone:786-262-5273
Mailing Address - Fax:
Practice Address - Street 1:571 SW 89TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-2338
Practice Address - Country:US
Practice Address - Phone:786-262-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-13
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-19-35110103K00000X
FL11006468363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily