Provider Demographics
NPI:1194483248
Name:GUTIERREZ HEREREA, JURIELMA
Entity type:Individual
Prefix:
First Name:JURIELMA
Middle Name:
Last Name:GUTIERREZ HEREREA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21895 CRESCENT PARK SQ APT 303
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-4435
Mailing Address - Country:US
Mailing Address - Phone:571-888-4750
Mailing Address - Fax:
Practice Address - Street 1:2978 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-6253
Practice Address - Country:US
Practice Address - Phone:703-934-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605958225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant