Healthcare Provider Details

I. General information

NPI: 1245086420
Provider Name (Legal Business Name): SANDRA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 04/29/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9735 TEAK LN.
MESILLA PARK NM
88047
US

IV. Provider business mailing address

9735 TEAK LN.
MESILLA PARK NM
88047
US

V. Phone/Fax

Practice location:
  • Phone: 575-649-6375
  • Fax:
Mailing address:
  • Phone: 575-649-6375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: