Provider Demographics
NPI:1891034807
Name:HEREDIA, JOSE ANGEL (RN NURSE)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ANGEL
Last Name:HEREDIA
Suffix:
Gender:M
Credentials:RN NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2343 SIESTA LN
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-5946
Mailing Address - Country:US
Mailing Address - Phone:407-279-7986
Mailing Address - Fax:
Practice Address - Street 1:2343 SIESTA LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-5946
Practice Address - Country:US
Practice Address - Phone:407-279-7986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9343438163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid