Healthcare Provider Details

I. General information

NPI: 1336780816
Provider Name (Legal Business Name): STEPHANIE MARIE HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 E ARROW HWY # 17
POMONA CA
91767-2535
US

IV. Provider business mailing address

831 E ARROW HWY # 17
POMONA CA
91767-2535
US

V. Phone/Fax

Practice location:
  • Phone: 909-398-4383
  • Fax:
Mailing address:
  • Phone: 909-626-4244
  • Fax:

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: