Healthcare Provider Details

I. General information

NPI: 1629207378
Provider Name (Legal Business Name): HEIDI VIVIAN CIPOLLONE HERRERA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 RANCHO NIGUEL RD STE 110
LAGUNA NIGUEL CA
92677-7373
US

IV. Provider business mailing address

24422 AVENIDA DE LA CARLOTA STE 300
LAGUNA HILLS CA
92653-3628
US

V. Phone/Fax

Practice location:
  • Phone: 949-448-8821
  • Fax: 949-448-8831
Mailing address:
  • Phone: 949-599-2434
  • Fax: 949-599-2430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA122576
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080T0002X
TaxonomyPediatric Medical Toxicology Physician
License NumberA122576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: