Healthcare Provider Details

I. General information

NPI: 1508511452
Provider Name (Legal Business Name): AMANDA PRISCILLA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10862 CALLE VERDE
LA MESA CA
91941-7340
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-7439
  • Fax:
Mailing address:
  • Phone: 858-554-7439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number61008
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: