Healthcare Provider Details

I. General information

NPI: 1942791777
Provider Name (Legal Business Name): JOHANA D HERNANDEZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5710 N BROADWAY ST
CHICAGO IL
60660-4302
US

IV. Provider business mailing address

14818 KILDARE AVE
MIDLOTHIAN IL
60445-3338
US

V. Phone/Fax

Practice location:
  • Phone: 773-728-1000
  • Fax:
Mailing address:
  • Phone: 224-283-4015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041439038
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: