Provider Demographics
NPI:1497879845
Name:HERNANDEZ, WANDA (MS)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7831 RUNNYMEDE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2751
Mailing Address - Country:US
Mailing Address - Phone:678-596-6716
Mailing Address - Fax:770-960-9664
Practice Address - Street 1:7831 RUNNYMEDE DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2751
Practice Address - Country:US
Practice Address - Phone:678-596-6716
Practice Address - Fax:770-960-9664
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator