Provider Demographics
NPI:1154527166
Name:HERNANDEZ, ANTONIA (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:ANTONIA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 PAWLAK PKWY
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9401
Mailing Address - Country:US
Mailing Address - Phone:815-215-3300
Mailing Address - Fax:815-215-3400
Practice Address - Street 1:1004 PAWLAK PKWY
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9401
Practice Address - Country:US
Practice Address - Phone:815-215-3400
Practice Address - Fax:815-215-3400
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL209019331363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1154527166Medicaid