Healthcare Provider Details

I. General information

NPI: 1679287957
Provider Name (Legal Business Name): MAYRA ROMAN HERNANDEZ FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N EUCLID AVE STE B
UPLAND CA
91786-8323
US

IV. Provider business mailing address

PO BOX 3356
FONTANA CA
92334-3356
US

V. Phone/Fax

Practice location:
  • Phone: 909-920-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95022573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: