Basic Information
| Provider Information | |||||||||
| NPI: | 1457864191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | YESSICA | ||||||||
| MiddleName: | KARINA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACOME MAGANA | ||||||||
| OtherFirstName: | YESSICA | ||||||||
| OtherMiddleName: | KARINA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | JESSICA MAGANA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1421 GUERNEVILLE RD STE 218 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954037255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075767700 | ||||||||
| FaxNumber: | 7075767744 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 GUERNEVILLE RD STE 218 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954037255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075767700 | ||||||||
| FaxNumber: | 7075767744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2017 | ||||||||
| LastUpdateDate: | 11/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.