Healthcare Provider Details

I. General information

NPI: 1053039065
Provider Name (Legal Business Name): VINCENT ANTHONY HERRERA-MALDONADO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 CAMFIELD AVE
COMMERCE CA
90040-1502
US

IV. Provider business mailing address

18080 ORANGE WAY
FONTANA CA
92335-4159
US

V. Phone/Fax

Practice location:
  • Phone: 323-725-8751
  • Fax:
Mailing address:
  • Phone: 562-656-6564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number95164312
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95164312
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number95164312
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number95164312
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95033361
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: