Provider Demographics
NPI:1376280560
Name:HERNANDEZ, CITLALI
Entity Type:Individual
Prefix:
First Name:CITLALI
Middle Name:
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 1:3380 LA SIERRA AVE # 104-242
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5271
Mailing Address - Country:US
Mailing Address - Phone:951-299-7645
Mailing Address - Fax:951-299-7510
Practice Address - Street 1:5425 SIERRA VISTA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3113
Practice Address - Country:US
Practice Address - Phone:951-299-7645
Practice Address - Fax:951-299-7510
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46-1597137Medicaid