Provider Demographics
NPI:1306479340
Name:HERNANDEZ, LICCY (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:LICCY
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 S MARTIN LUTHER KING JR AVE APT 704
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-5734
Mailing Address - Country:US
Mailing Address - Phone:617-285-1529
Mailing Address - Fax:
Practice Address - Street 1:8902 N DALE MABRY HWY STE 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-1579
Practice Address - Country:US
Practice Address - Phone:813-513-2156
Practice Address - Fax:813-513-2166
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FL110282211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No104100000XBehavioral Health & Social Service ProvidersSocial Worker