Provider Demographics
NPI:1679725147
Name:HERNANDEZ GRAUDELAMA, GISELLE MARIE (MD)
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:MARIE
Last Name:HERNANDEZ GRAUDELAMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GISELLE
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2200 FOWLER GROVE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5597
Mailing Address - Country:US
Mailing Address - Phone:407-656-0042
Mailing Address - Fax:
Practice Address - Street 1:2200 FOWLER GROVE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-5597
Practice Address - Country:US
Practice Address - Phone:407-656-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08472800208000000X
FLME111384208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics