Basic Information
| Provider Information | |||||||||
| NPI: | 1184262701 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | SISSI | ||||||||
| MiddleName: | D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7474 GREENWAY CENTER DR | ||||||||
| Address2: | |||||||||
| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207703504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014413050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7474 GREENWAY CENTER DR | ||||||||
| Address2: | |||||||||
| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207703504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014413050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2019 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | RN237980 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | R237980 | 01 | MD | CRNP LICENSE | OTHER |