Provider Demographics
NPI:1821317090
Name:HERBST, CONNIE MARIE (RN)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:HERBST
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:MARIE
Other - Last Name:HERBST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:30412 SANDTRAP DR
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-1429
Mailing Address - Country:US
Mailing Address - Phone:818-851-9330
Mailing Address - Fax:
Practice Address - Street 1:1911 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2612
Practice Address - Country:US
Practice Address - Phone:805-981-5423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA645392163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse