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General NPI Number Information
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NPI Number | 1366206252
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Entity Type | Organization
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Legal Business Name | PSYCHIATRY 121 PLLC
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Dates
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Enumeration Date | 02/12/2024
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Last Update Date | 02/12/2024
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Provider Practice Location Address
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Address Line | 1010 W HAYS ST
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City | BOISE
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State | ID
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Zip | 83702-5435
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Country | US
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Telephone | 949-281-9132
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Fax |
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Provider Business Mailing Address
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Address Line | 1010 W HAYS ST
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City | BOISE
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State | ID
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Zip | 83702-5435
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | ANGELA G HERNANDEZ
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Credential | PMHNP
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Telephone | 949-281-9132
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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