Provider Demographics
NPI:1215277504
Name:HERNANDEZ, RICKIE LYNN
Entity type:Individual
Prefix:
First Name:RICKIE
Middle Name:LYNN
Last Name: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 1:48617 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-9791
Mailing Address - Country:US
Mailing Address - Phone:616-403-9430
Mailing Address - Fax:269-427-7009
Practice Address - Street 1:48617 36TH AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-9791
Practice Address - Country:US
Practice Address - Phone:616-403-9430
Practice Address - Fax:269-427-7009
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF800328155171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor