Provider Demographics
NPI:1932700481
Name:HERNANDEZ, CHAMPANGE MONAE
Entity Type:Individual
Prefix:
First Name:CHAMPANGE
Middle Name:MONAE
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 1:1516 E TROPICANA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6525
Mailing Address - Country:US
Mailing Address - Phone:725-214-7776
Mailing Address - Fax:725-214-7768
Practice Address - Street 1:1516 E TROPICANA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6525
Practice Address - Country:US
Practice Address - Phone:725-214-7776
Practice Address - Fax:725-214-7768
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2102988069374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide