MEDICARE: MARY ELLEN HERNANDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1881023562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN HERNANDEZ

Provider Business Mailing Address
First Line	:	5179 SILENT VALLEY AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-7056
Country	:	US
Telephone Number	:	702-628-3846
Fax Number	:

Provider Business Practice Location Address
First Line	:	7465 W LAKE MEAD BLVD STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1033
Country	:	US
Telephone Number	:	702-658-9563
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	11/04/2013

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