1134185960 NPI number — DR. ILSE P HERNANDEZ-ALLEN DOM

Table of content: DR. ILSE P HERNANDEZ-ALLEN DOM (NPI 1134185960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134185960 NPI number — DR. ILSE P HERNANDEZ-ALLEN DOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERNANDEZ-ALLEN
Provider First Name:
ILSE
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DOM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HERNANDEZ
Provider Other First Name:
ILSE
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DOM
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1134185960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4724 TRENTON HILLS DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIO RANCHO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87144-8615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-573-1288
Provider Business Mailing Address Fax Number:
505-217-1721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4080 RIDGE ROCK RD SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-7649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-573-1288
Provider Business Practice Location Address Fax Number:
505-217-1721
Provider Enumeration Date:
04/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  794 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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