Healthcare Provider Details

I. General information

NPI: 1376830372
Provider Name (Legal Business Name): AGNES HERNANDEZ-GRANDE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 03/11/2025
Certification Date: 03/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 WASHINGTON ST
NEWTON MA
02462-1607
US

IV. Provider business mailing address

55 FRUIT ST
BOSTON MA
02114-2621
US

V. Phone/Fax

Practice location:
  • Phone: 617-243-6000
  • Fax:
Mailing address:
  • Phone: 617-724-4260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10039704
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number277302
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: