Provider Demographics
NPI:1538779152
Name:HERNANDEZ, LIDIA (ACNP)
Entity type:Individual
Prefix:MS
First Name:LIDIA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 1156
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3852
Mailing Address - Country:US
Mailing Address - Phone:312-563-2762
Mailing Address - Fax:
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1700
Practice Address - Country:US
Practice Address - Phone:847-570-2760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020027221363LA2100X
IL209021475363L00000X
IL209.021475363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420089045Medicaid