Healthcare Provider Details

I. General information

NPI: 1164351599
Provider Name (Legal Business Name): KATHLEEN DAISY HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 PAINTED MIRAGE RD STE 120
LAS VEGAS NV
89149-4582
US

IV. Provider business mailing address

6300 MCCARRAN ST UNIT 1030
N LAS VEGAS NV
89081-8115
US

V. Phone/Fax

Practice location:
  • Phone: 702-898-7633
  • Fax:
Mailing address:
  • Phone: 361-905-3882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-1630
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: