Provider Demographics
NPI:1033212691
Name:HEREDIA, ROSA ELENA (FNP)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:ELENA
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 N JACKSON AVE
Mailing Address - Street 2:STE 209
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1604
Mailing Address - Country:US
Mailing Address - Phone:408-258-3724
Mailing Address - Fax:408-258-3736
Practice Address - Street 1:244 N JACKSON AVE
Practice Address - Street 2:STE 209
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1604
Practice Address - Country:US
Practice Address - Phone:408-258-3724
Practice Address - Fax:408-258-3736
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP9507363L00000X, 363LX0001X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily