Healthcare Provider Details

I. General information

NPI: 1023983574
Provider Name (Legal Business Name): KRYSTAL AMANDA VELASCO HERNANDEZ PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4361 LATHAM ST STE 220
RIVERSIDE CA
92501-1767
US

IV. Provider business mailing address

4361 LATHAM ST STE 220
RIVERSIDE CA
92501-1767
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax:
Mailing address:
  • Phone: 858-279-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95190746
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95037330
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: