Provider Demographics
NPI:1396905972
Name:HERRON, BETTY ANN (OWNER OPERATOR)
Entity type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:ANN
Last Name:HERRON
Suffix:
Gender:F
Credentials:OWNER OPERATOR
Other - Prefix:MR
Other - First Name:KENNETH
Other - Middle Name:EDWARD
Other - Last Name:HERRON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CHAIRMAN
Mailing Address - Street 1:7200 SAN MIGUEL DR
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-5031
Mailing Address - Country:US
Mailing Address - Phone:727-848-3468
Mailing Address - Fax:727-842-6401
Practice Address - Street 1:7200 SAN MIGUEL DR
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-5031
Practice Address - Country:US
Practice Address - Phone:727-848-3468
Practice Address - Fax:727-842-6401
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL332B00000XOtherCNT