Provider Demographics
NPI:1013567023
Name:HEREDIA, CAITLYN
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18330 N 79TH AVENUE
Mailing Address - Street 2:APARTMENT 1070
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18330 N 79TH AVENUE
Practice Address - Street 2:APARTMENT 1070
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:951-235-1187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty