Provider Demographics
NPI:1780072728
Name:HERNANDEZ, JUANA FATIMA
Entity type:Individual
Prefix:MISS
First Name:JUANA
Middle Name:FATIMA
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 1:1804 VILLA VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-3049
Mailing Address - Country:US
Mailing Address - Phone:702-370-6365
Mailing Address - Fax:
Practice Address - Street 1:1640 E FLAMINGO RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5280
Practice Address - Country:US
Practice Address - Phone:725-400-2513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator