Healthcare Provider Details

I. General information

NPI: 1225794571
Provider Name (Legal Business Name): ROSE V HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2021
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W 1ST ST STE 102
SANTA ANA CA
92701-5262
US

IV. Provider business mailing address

2627 W BROADWAY APT 9
ANAHEIM CA
92804-2173
US

V. Phone/Fax

Practice location:
  • Phone: 714-972-4921
  • Fax:
Mailing address:
  • Phone: 562-324-1338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95025014
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95205281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: