Healthcare Provider Details

I. General information

NPI: 1154527166
Provider Name (Legal Business Name): ANTONIA HERNANDEZ PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 PAWLAK PKWY
NEW LENOX IL
60451-9401
US

IV. Provider business mailing address

1004 PAWLAK PKWY
NEW LENOX IL
60451-9401
US

V. Phone/Fax

Practice location:
  • Phone: 815-215-3400
  • Fax: 815-215-3400
Mailing address:
  • Phone: 815-215-3300
  • Fax: 815-215-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209019331
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: