Healthcare Provider Details

I. General information

NPI: 1215120027
Provider Name (Legal Business Name): BRIDGETTE MARIE HERNANDEZ RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 S. 16TH ST.
GROVER BEACH CA
93433-2245
US

IV. Provider business mailing address

286 S. 16TH ST.
GROVER BEACH CA
93433
US

V. Phone/Fax

Practice location:
  • Phone: 805-472-7052
  • Fax: 805-474-7473
Mailing address:
  • Phone: 805-472-7052
  • Fax: 805-474-7473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN402321
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: