Provider Demographics
NPI:1770338196
Name:HERNANDEZ, CRYSTAL ANTOINETTE (MASSAGE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANTOINETTE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MASSAGE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 W SAN RAMON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2632
Mailing Address - Country:US
Mailing Address - Phone:559-284-5615
Mailing Address - Fax:
Practice Address - Street 1:3026 W SAN RAMON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-2632
Practice Address - Country:US
Practice Address - Phone:559-284-5615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50074225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist