Healthcare Provider Details

I. General information

NPI: 1407638737
Provider Name (Legal Business Name): KRISTINA MARIA HEREDIA I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NJ-35
CLIFFWOOD NJ
07721
US

IV. Provider business mailing address

4 STEPHEN ST
HAZLET NJ
07730-1825
US

V. Phone/Fax

Practice location:
  • Phone: 732-812-5489
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number26NR23933100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: