Provider Demographics
NPI:1033983069
Name:HERNANDEZ, AUDRENA GRACE
Entity Type:Individual
Prefix:
First Name:AUDRENA
Middle Name:GRACE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8343 ETIWANDA AVE APT E
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9694
Mailing Address - Country:US
Mailing Address - Phone:909-689-6396
Mailing Address - Fax:
Practice Address - Street 1:10604 N TRADEMARK PKWY
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5938
Practice Address - Country:US
Practice Address - Phone:909-484-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician