Healthcare Provider Details

I. General information

NPI: 1316355977
Provider Name (Legal Business Name): TONYA MARIE HEREDIA RN00136279
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MCJA-NUR UNIT 45011
APO AP
96343-5011
US

IV. Provider business mailing address

PSC 704 BOX 3783
APO AP
96338-0018
US

V. Phone/Fax

Practice location:
  • Phone: 315-263-4127
  • Fax:
Mailing address:
  • Phone: 360-200-0977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00136279
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: