Provider Demographics
NPI:1104016104
Name:HERNANDEZ, MAYRA MARLEN (RN)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:MARLEN
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W 113TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-1911
Mailing Address - Country:US
Mailing Address - Phone:323-733-1885
Mailing Address - Fax:323-733-1875
Practice Address - Street 1:3831 HUGHES AVE
Practice Address - Street 2:SUITE 604
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2751
Practice Address - Country:US
Practice Address - Phone:310-839-4381
Practice Address - Fax:310-815-2091
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 566430163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN 566430OtherBORAD OF REGISTERED NURSI
CANP 14783OtherBOARD OF REGISTERED NURIS