Provider Demographics
NPI:1578028908
Name:HERNANDEZ, SALAAM IMANI (CERTIFICATION ECD)
Entity Type:Individual
Prefix:
First Name:SALAAM
Middle Name:IMANI
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:CERTIFICATION ECD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 BLUE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-2902
Mailing Address - Country:US
Mailing Address - Phone:857-445-8419
Mailing Address - Fax:
Practice Address - Street 1:895 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124
Practice Address - Country:US
Practice Address - Phone:857-445-8419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000OtherNONE