Provider Demographics
NPI:1649753906
Name:HERNANDEZ, MARICELA FAUSTO
Entity Type:Individual
Prefix:
First Name:MARICELA
Middle Name:FAUSTO
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 1:15790 LARKSPUR ST
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-3549
Mailing Address - Country:US
Mailing Address - Phone:818-963-2524
Mailing Address - Fax:
Practice Address - Street 1:21000 PLUMMER ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-4903
Practice Address - Country:US
Practice Address - Phone:818-882-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program