Provider Demographics
NPI:1023774296
Name:HERNANDEZ, KEYRA (LD)
Entity type:Individual
Prefix:
First Name:KEYRA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 S LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1519
Mailing Address - Country:US
Mailing Address - Phone:806-771-8008
Mailing Address - Fax:
Practice Address - Street 1:2431 S LOOP 289
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1519
Practice Address - Country:US
Practice Address - Phone:806-771-8008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86964133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8QP890OtherBCBS