Healthcare Provider Details

I. General information

NPI: 1750077665
Provider Name (Legal Business Name): HEATHER LYNN HERNANDEZ FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER LYNN ROSE RN

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16390 N 59TH AVE STE 200
GLENDALE AZ
85306-1711
US

IV. Provider business mailing address

16390 N 59TH AVE STE 200
GLENDALE AZ
85306-1711
US

V. Phone/Fax

Practice location:
  • Phone: 623-334-4000
  • Fax: 623-334-4400
Mailing address:
  • Phone: 623-334-4000
  • Fax: 623-334-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number290483
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: