Provider Demographics
NPI:1073010500
Name:HERNANDEZ, PRISCILLA OS
Entity Type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:OS
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:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-0162
Mailing Address - Country:US
Mailing Address - Phone:229-873-7100
Mailing Address - Fax:
Practice Address - Street 1:605 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:GA
Practice Address - Zip Code:31647-7141
Practice Address - Country:US
Practice Address - Phone:229-873-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor