Healthcare Provider Details

I. General information

NPI: 1356186282
Provider Name (Legal Business Name): INGRID ISABEL HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9639 MADRONA DR
FONTANA CA
92335-5602
US

IV. Provider business mailing address

600 N HIGHLAND SPRINGS AVE
BANNING CA
92220-3046
US

V. Phone/Fax

Practice location:
  • Phone: 321-831-9969
  • Fax:
Mailing address:
  • Phone: 951-845-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95033340
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11033759
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: