Provider Demographics
NPI:1427775881
Name:HEREDERO DIAZ, MARISE
Entity type:Individual
Prefix:
First Name:MARISE
Middle Name:
Last Name:HEREDERO DIAZ
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 1:14401 SW 114TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6655
Mailing Address - Country:US
Mailing Address - Phone:786-346-4305
Mailing Address - Fax:
Practice Address - Street 1:14401 SW 114TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6655
Practice Address - Country:US
Practice Address - Phone:786-346-4305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11017395363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner