Provider Demographics
NPI:1467565093
Name:HERTZ, DEIDRA A (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:DEIDRA
Middle Name:A
Last Name:HERTZ
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DOCTORS DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564
Mailing Address - Country:US
Mailing Address - Phone:228-818-0053
Mailing Address - Fax:228-818-0110
Practice Address - Street 1:4 DOCTORS DR
Practice Address - Street 2:SUITE C
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564
Practice Address - Country:US
Practice Address - Phone:228-818-0053
Practice Address - Fax:228-818-0110
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR783864363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSQ32141Medicare UPIN
MS04857509Medicare ID - Type Unspecified