Provider Demographics
NPI:1053054072
Name:HERNANDEZ, OTTONIEL (NP)
Entity type:Individual
Prefix:MR
First Name:OTTONIEL
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SW 62ND AVE STE 124
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3009
Mailing Address - Country:US
Mailing Address - Phone:305-662-8316
Mailing Address - Fax:305-663-8513
Practice Address - Street 1:3100 SW 62ND AVE STE 124
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3009
Practice Address - Country:US
Practice Address - Phone:305-662-8316
Practice Address - Fax:305-663-8513
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11018958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily