Provider Demographics
NPI:1770509416
Name:HERRERA MURAIDA, JOLYNN
Entity Type:Individual
Prefix:
First Name:JOLYNN
Middle Name:
Last Name:HERRERA MURAIDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5805 CANYON VISTA DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6617
Mailing Address - Country:US
Mailing Address - Phone:505-828-0577
Mailing Address - Fax:
Practice Address - Street 1:5808 MCLEOD RD NE
Practice Address - Street 2:SUITE L
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2455
Practice Address - Country:US
Practice Address - Phone:505-710-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-972084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME0162Medicaid
NME0162Medicaid