Provider Demographics
NPI:1629721881
Name:HERNANDEZ, MYRA ALEJANDRA
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:ALEJANDRA
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:ALEJANDRA
Other - Last Name:RAMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5005 CANYON CREST DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-7721
Mailing Address - Country:US
Mailing Address - Phone:747-224-2090
Mailing Address - Fax:
Practice Address - Street 1:5005 CANYON CREST DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7721
Practice Address - Country:US
Practice Address - Phone:747-224-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC5398390200000X
CAAMFT108306390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program