Healthcare Provider Details

I. General information

NPI: 1194617845
Provider Name (Legal Business Name): SHEYENNE DAWN HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1248 E 17TH ST
IDAHO FALLS ID
83404-6126
US

IV. Provider business mailing address

69 N 900 W
BLACKFOOT ID
83221-5390
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-1026
  • Fax:
Mailing address:
  • Phone: 208-681-3013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberLSW-31953
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW45186
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: