Provider Demographics
NPI:1528406402
Name:HERRAIZ, JESSICA (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HERRAIZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-CNP
Mailing Address - Street 1:2222 S HARBOR CITY BLVD
Mailing Address - Street 2:STE 610
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5591
Mailing Address - Country:US
Mailing Address - Phone:321-723-7716
Mailing Address - Fax:321-541-1581
Practice Address - Street 1:2222 S HARBOR CITY BLVD
Practice Address - Street 2:STE 610
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5591
Practice Address - Country:US
Practice Address - Phone:321-723-7716
Practice Address - Fax:321-541-1581
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN301203363LA2100X
FLAPRN11006608363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108097000Medicaid