Provider Demographics
NPI:1568500833
Name:HERNANDEZ, CONNIE
Entity Type:Individual
Prefix:
First Name:CONNIE
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 1:1230 LA LOMA ROAD
Mailing Address - Street 2:
Mailing Address - City:ANTON CHICO
Mailing Address - State:NM
Mailing Address - Zip Code:87711-9501
Mailing Address - Country:US
Mailing Address - Phone:575-427-8026
Mailing Address - Fax:
Practice Address - Street 1:325 NORTH BERGIN LANE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-2430
Practice Address - Country:US
Practice Address - Phone:505-632-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist