Provider Demographics
NPI:1942581707
Name:HEREDIA, JUDITH (CRNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT STREET
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-955-4538
Mailing Address - Fax:215-923-9186
Practice Address - Street 1:833 CHESTNUT STREET
Practice Address - Street 2:SUITE 301
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-4538
Practice Address - Fax:215-923-9186
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011335363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily