Provider Demographics
NPI:1386478147
Name:HERNANDEZ, CHRISTINA (LSAA, CHW)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:
Credentials:LSAA, CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5600
Mailing Address - Country:US
Mailing Address - Phone:505-397-5172
Mailing Address - Fax:
Practice Address - Street 1:1609 CAMINO RANCHEROS
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6857
Practice Address - Country:US
Practice Address - Phone:505-870-1236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMS1-1635172V00000X
NMCTB-2024-0172101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker