Provider Demographics
NPI:1295209005
Name:HERNDON, SECISHA MARIE
Entity Type:Individual
Prefix:
First Name:SECISHA
Middle Name:MARIE
Last Name:HERNDON
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 1:13708 ALVIN AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44105-7118
Mailing Address - Country:US
Mailing Address - Phone:216-673-1461
Mailing Address - Fax:
Practice Address - Street 1:4903 E 96TH ST
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2117
Practice Address - Country:US
Practice Address - Phone:216-673-1461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH139495164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse