Provider Demographics
NPI:1164885745
Name:HERNANDEZ, ANGEL CUSTODIO (APN-CNP)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:CUSTODIO
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:APN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5218 N KIMBALL AVE
Mailing Address - Street 2:APT. 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-4729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 RIDGE AVE.
Practice Address - Street 2:PALLIATIVE CARE
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-503-4222
Practice Address - Fax:847-503-4220
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.013700363LF0000X
IL209013700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily