Provider Demographics
NPI:1225794571
Name:HERNANDEZ, ROSE V
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:V
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 1:2627 W BROADWAY APT 9
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-2173
Mailing Address - Country:US
Mailing Address - Phone:562-324-1338
Mailing Address - Fax:
Practice Address - Street 1:220 W 1ST ST STE 102
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5262
Practice Address - Country:US
Practice Address - Phone:714-972-4921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95205281163W00000X
CA95025014363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse