Provider Demographics
NPI:1710321369
Name:HUMPHRIES, HEIDI (RN,BSN,IBCLC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:RN,BSN,IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10644 SW 17TH PL
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-7159
Mailing Address - Country:US
Mailing Address - Phone:954-471-4429
Mailing Address - Fax:
Practice Address - Street 1:10644 SW 17TH PL
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-7159
Practice Address - Country:US
Practice Address - Phone:954-471-4429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN2904522163W00000X
FL102-18249163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse