Provider Demographics
NPI:1164048666
Name:HERNANDEZ, KELLY VANESSA JR
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:VANESSA
Last Name:HERNANDEZ
Suffix:JR
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 1:4709 CHERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-1329
Mailing Address - Country:US
Mailing Address - Phone:240-701-1132
Mailing Address - Fax:
Practice Address - Street 1:4709 CHERRY HILL RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-1329
Practice Address - Country:US
Practice Address - Phone:240-701-1132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDACTIVE3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant