Provider Demographics
NPI:1255103651
Name:HERNANDEZ, MICHELLE (BA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2095 7TH ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4348
Mailing Address - Country:US
Mailing Address - Phone:451-205-8641
Mailing Address - Fax:
Practice Address - Street 1:1450 UNIVERSITY AVE # F-508
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-4467
Practice Address - Country:US
Practice Address - Phone:415-205-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health