Provider Demographics
NPI:1861272213
Name:HERNANDEZ, MARISA RENE (RD)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:RENE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3381 WALNUT BLVD STE 200B
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-4495
Mailing Address - Country:US
Mailing Address - Phone:925-252-5922
Mailing Address - Fax:
Practice Address - Street 1:3381 WALNUT BLVD STE 200B
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-4495
Practice Address - Country:US
Practice Address - Phone:925-252-5922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86359383133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered