Provider Demographics
NPI:1235304031
Name:HERNANDEZ, SIDDIQUI ROSE (CRNP PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SIDDIQUI
Middle Name:ROSE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:CRNP PMHNP-BC
Other - Prefix:
Other - First Name:ROSEMARY
Other - Middle Name:LEIGH
Other - Last Name:COLLINS-SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP PMHNP-BC
Mailing Address - Street 1:PO BOX 17779
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-0779
Mailing Address - Country:US
Mailing Address - Phone:480-718-0568
Mailing Address - Fax:
Practice Address - Street 1:123 E BASELINE RD STE D104
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1291
Practice Address - Country:US
Practice Address - Phone:480-718-0568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN213648163WP0808X
MO2010039446363LP0808X
MDR205786363LP0808X
AZAP11103363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD443609100Medicaid
211833Medicare Oscar/Certification
S118Medicare PIN