Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1053889154 |
---|---|
Provider Name | Jessy Hernandes |
First Address | Henderson, NV 89015-5782 |
Second Address | Henderson, NV 89015-5782 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2018 |
Last Update Date | 06/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1704479623 | (05) | NV |