Provider Demographics
NPI:1952914467
Name:HERNANDEZ, MA DOLORES
Entity type:Individual
Prefix:
First Name:MA
Middle Name:DOLORES
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 1:13549 ELSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-8463
Mailing Address - Country:US
Mailing Address - Phone:951-229-1129
Mailing Address - Fax:
Practice Address - Street 1:1001 S HALE AVE SPC 54
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-2177
Practice Address - Country:US
Practice Address - Phone:760-729-8295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD5689720OtherDRIVER LICENSE