Provider Demographics
NPI:1437523479
Name:HERICKS, DESIREE M (CNM)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:M
Last Name:HERICKS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:201 RIDGE ST STE 312
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4643
Practice Address - Country:US
Practice Address - Phone:712-396-7880
Practice Address - Fax:712-396-7885
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAB142120367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026211300Medicaid
NE10026480117Medicaid
IA1437523479Medicaid