Provider Demographics
NPI:1811779077
Name:HERNANDEZ, AGNES PARDO SR
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:PARDO
Last Name:HERNANDEZ
Suffix:SR
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 1:2658 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7418
Mailing Address - Country:US
Mailing Address - Phone:904-444-7655
Mailing Address - Fax:
Practice Address - Street 1:2658 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7418
Practice Address - Country:US
Practice Address - Phone:904-444-7655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-298842106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician