Healthcare Provider Details

I. General information

NPI: 1699010306
Provider Name (Legal Business Name): CAROL ANN HEREDIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E AZTEC AVE
GALLUP NM
87301-5509
US

IV. Provider business mailing address

1000 EAST AZTEC
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-721-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-08084
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: