Healthcare Provider Details

I. General information

NPI: 1518436781
Provider Name (Legal Business Name): STEPHANIE HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2018
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 KEARNY VILLA RD STE 165
SAN DIEGO CA
92123-1954
US

IV. Provider business mailing address

1250 5TH AVE APT 306
CHULA VISTA CA
91911-3038
US

V. Phone/Fax

Practice location:
  • Phone: 858-576-1700
  • Fax:
Mailing address:
  • Phone: 619-863-3793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: