Provider Demographics
NPI:1144828567
Name:HERNANDEZ, ROSE
Entity type:Individual
Prefix:
First Name:ROSE
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 1:15121 SW MILLIKAN WAY APT 318
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-5191
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7345
Practice Address - Country:US
Practice Address - Phone:503-666-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant