Provider Demographics
NPI:1699196303
Name:HEREDIA, ROSA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:ROSA
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 MACE AVE APT E5
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-9131
Mailing Address - Country:US
Mailing Address - Phone:917-428-6599
Mailing Address - Fax:
Practice Address - Street 1:234 EAST 149TH STREET
Practice Address - Street 2:MEDICINE DEPARTMENT 8TH FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451
Practice Address - Country:US
Practice Address - Phone:718-579-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338421363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care