Provider Demographics
NPI:1699337329
Name:HERNANDEZ, ROSE M
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:M
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 1:220 GLEN ELLYN RD APT 206
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2804
Mailing Address - Country:US
Mailing Address - Phone:630-210-1785
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2345
Practice Address - Country:US
Practice Address - Phone:815-939-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0265336363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily