Provider Demographics
NPI:1336487784
Name:BOUMA HERNANDEZ, LISA JEANNE (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JEANNE
Last Name:BOUMA HERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3236 N POINCIANA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-4688
Mailing Address - Country:US
Mailing Address - Phone:407-635-5952
Mailing Address - Fax:407-636-7802
Practice Address - Street 1:3236 N POINCIANA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-4688
Practice Address - Country:US
Practice Address - Phone:076-355-9524
Practice Address - Fax:407-636-7802
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME166907208000000X
NY276845208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics