Provider Demographics
NPI:1386455541
Name:HERNANDEZ, MARISA
Entity type:Individual
Prefix:
First Name:MARISA
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 1:31760 CASINO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4561
Mailing Address - Country:US
Mailing Address - Phone:951-471-7600
Mailing Address - Fax:
Practice Address - Street 1:31760 CASINO DR STE 100
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4561
Practice Address - Country:US
Practice Address - Phone:951-471-4600
Practice Address - Fax:951-471-4623
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker