Provider Demographics
NPI:1831723030
Name:HEREDIA, GUADALUPE (BRN)
Entity type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:BRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 ROSS AVE EL CENTRO CA
Mailing Address - Street 2:EL CENTRO
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 ROSS AVE EL CENTRO CA
Practice Address - Street 2:EL CENTRO
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243
Practice Address - Country:US
Practice Address - Phone:760-339-7146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA438451163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse