Provider Demographics
NPI:1417736349
Name:HERNANDEZ, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
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 1:109 HILLSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93437-1488
Mailing Address - Country:US
Mailing Address - Phone:248-830-3420
Mailing Address - Fax:
Practice Address - Street 1:425 MOONCREST LN
Practice Address - Street 2:
Practice Address - City:ORCUTT
Practice Address - State:CA
Practice Address - Zip Code:93455-3765
Practice Address - Country:US
Practice Address - Phone:805-937-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker