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 1:3464 AVALON PARK EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7363
Mailing Address - Country:US
Mailing Address - Phone:407-635-3020
Mailing Address - Fax:321-203-4607
Practice Address - Street 1:3464 AVALON PARK EAST BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7363
Practice Address - Country:US
Practice Address - Phone:407-635-3020
Practice Address - Fax:321-203-4607
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276845208000000X
FLME166907208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124579800Medicaid