Provider Demographics
NPI:1245796481
Name:HERNANDEZ, IDALIA ELIZABETH
Entity type:Individual
Prefix:
First Name:IDALIA
Middle Name:ELIZABETH
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 1:12050 LA SALLE OAKS
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-4001
Mailing Address - Country:US
Mailing Address - Phone:936-828-9444
Mailing Address - Fax:
Practice Address - Street 1:801 BOWERS BLVD
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77341-0001
Practice Address - Country:US
Practice Address - Phone:936-294-2649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer