Provider Demographics
NPI:1083118301
Name:HERTRICH, JOY
Entity Type:Individual
Prefix:
First Name:JOY
Middle Name:
Last Name:HERTRICH
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 1:862 SW CARMELITE ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:862 SW CARMELITE ST
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1830
Practice Address - Country:US
Practice Address - Phone:772-985-7469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9239812163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9239812OtherLICENSE