Provider Demographics
NPI:1346907458
Name:HERNANDEZ, SHELLY VANESSA (RDH)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:VANESSA
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:964 AJAX STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-0001
Mailing Address - Country:US
Mailing Address - Phone:904-546-7000
Mailing Address - Fax:
Practice Address - Street 1:964 AJAX STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-0001
Practice Address - Country:US
Practice Address - Phone:904-546-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18337124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty