Provider Demographics
NPI:1871381863
Name:HERNANDEZ, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:
Credentials:
Other - Prefix:MR
Other - First Name:NIKO
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:47915 OASIS ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6950
Mailing Address - Country:US
Mailing Address - Phone:760-863-8600
Mailing Address - Fax:
Practice Address - Street 1:47915 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6950
Practice Address - Country:US
Practice Address - Phone:760-863-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-IBWEHP175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist