Provider Demographics
NPI:1356854517
Name:HERNANDEZ, RACHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10960 CRESTWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINBURG
Mailing Address - State:AR
Mailing Address - Zip Code:72946-2948
Mailing Address - Country:US
Mailing Address - Phone:479-430-3355
Mailing Address - Fax:
Practice Address - Street 1:1004 SE 5TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6032
Practice Address - Country:US
Practice Address - Phone:479-254-6717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA4071208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation