Healthcare Provider Details

I. General information

NPI: 1548807050
Provider Name (Legal Business Name): CAMELLA L HERNANDEZ FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2100
US

IV. Provider business mailing address

3001 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2100
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-7000
  • Fax:
Mailing address:
  • Phone: 505-994-7397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number58323
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: