Healthcare Provider Details

I. General information

NPI: 1679220081
Provider Name (Legal Business Name): MRS. DEISY GRACIELA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2022
Last Update Date: 03/05/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N RENO ST
LOS ANGELES CA
90026-4656
US

IV. Provider business mailing address

150 N RENO ST
LOS ANGELES CA
90026-4656
US

V. Phone/Fax

Practice location:
  • Phone: 213-380-7298
  • Fax: 213-384-0951
Mailing address:
  • Phone: 213-380-7298
  • Fax: 213-384-0951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: