Provider Demographics
NPI:1902315427
Name:HERNANDEZ, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 S FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-4401
Mailing Address - Country:US
Mailing Address - Phone:424-258-0124
Mailing Address - Fax:
Practice Address - Street 1:1086 S FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-4401
Practice Address - Country:US
Practice Address - Phone:424-258-0124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2023-07-11
Deactivation Date:2020-05-11
Deactivation Code:
Reactivation Date:2020-09-23
Provider Licenses
StateLicense IDTaxonomies
CAPA58000363A00000X
FL9110737363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant