Provider Demographics
NPI:1780730440
Name:HERZOG, NINA JEAN (ACNP-BC)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:JEAN
Last Name:HERZOG
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8208 LOUISIANA BLVD NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1757
Mailing Address - Country:US
Mailing Address - Phone:505-858-1222
Mailing Address - Fax:505-858-1224
Practice Address - Street 1:8208 LOUISIANA BLVD NE
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1757
Practice Address - Country:US
Practice Address - Phone:505-858-1222
Practice Address - Fax:505-858-1224
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR49167363LA2100X
NMCNP01217363L00000X
NMR49167363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR49167OtherBNE LICENSE
MD2006009954OtherANCC CERTIFICATION
NM87657317Medicaid
TXR49167OtherBNE LICENSE
NM87657317Medicaid