Provider Demographics
NPI:1306570726
Name:HEREDIA, MIAMARIA
Entity type:Individual
Prefix:
First Name:MIAMARIA
Middle Name:
Last Name:HEREDIA
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 1:2214 S 96TH EAST AVE APT A
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-3909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-4429
Practice Address - Country:US
Practice Address - Phone:773-819-8699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator