Provider Demographics
NPI:1265101018
Name:HERRON, ROYDELL JR
Entity type:Individual
Prefix:MR
First Name:ROYDELL
Middle Name:
Last Name:HERRON
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 BETTY MANLEY RD
Mailing Address - Street 2:
Mailing Address - City:DENMARK
Mailing Address - State:TN
Mailing Address - Zip Code:38391-1854
Mailing Address - Country:US
Mailing Address - Phone:731-217-6586
Mailing Address - Fax:
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3923
Practice Address - Country:US
Practice Address - Phone:731-541-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN211952163WC0200X
TN31490367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine