Provider Demographics
NPI:1144078635
Name:HERNANDEZ, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
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 1:24550 E LITTLE THIRD ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-4936
Mailing Address - Country:US
Mailing Address - Phone:909-413-7705
Mailing Address - Fax:
Practice Address - Street 1:1260 E ARROW HWY BLDG E
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4984
Practice Address - Country:US
Practice Address - Phone:909-932-1069
Practice Address - Fax:909-932-1087
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42786167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician