Provider Demographics
NPI:1104417708
Name:ROMAN, MICHELLE ANGEL HERNANDEZ
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANGEL HERNANDEZ
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANGEL
Other - Last Name:HERNANDEZ ROMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2707 CELANESE RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-9406
Mailing Address - Country:US
Mailing Address - Phone:803-366-4157
Mailing Address - Fax:
Practice Address - Street 1:2707 CELANESE RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-9406
Practice Address - Country:US
Practice Address - Phone:803-366-4157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily