Provider Demographics
NPI:1265790679
Name:HERNANDEZ, KIMBERLY STAR
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:STAR
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 1:9925 W RUSSELL RD UNIT 2081
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5604
Mailing Address - Country:US
Mailing Address - Phone:702-684-1771
Mailing Address - Fax:
Practice Address - Street 1:9925 W RUSSELL RD UNIT 2081
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5604
Practice Address - Country:US
Practice Address - Phone:702-684-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner