Provider Demographics
NPI:1154469344
Name:HERNANDEZ, MAYRA CAROLINA (LVN)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:CAROLINA
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12441 SQUAW VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8843
Mailing Address - Country:US
Mailing Address - Phone:760-912-0096
Mailing Address - Fax:
Practice Address - Street 1:12441 SQUAW VALLEY LN
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8843
Practice Address - Country:US
Practice Address - Phone:760-912-0096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 192866164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN003720OtherMEDI-CAL PROVIDER NUMBER