Provider Demographics
NPI:1407638737
Name:HEREDIA, KRISTINA MARIA I
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIA
Last Name:HEREDIA
Suffix:I
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 1:4 STEPHEN ST
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-1825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 NJ-35
Practice Address - Street 2:
Practice Address - City:CLIFFWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07721
Practice Address - Country:US
Practice Address - Phone:732-812-5489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR23933100163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)