Provider Demographics
NPI:1588155709
Name:HEREDIA, MONICA I
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:I
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 1:2815 W FORD AVE APT 1031
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-6666
Mailing Address - Country:US
Mailing Address - Phone:702-502-0757
Mailing Address - Fax:
Practice Address - Street 1:1951 STELLA LAKE ST STE 36
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2144
Practice Address - Country:US
Practice Address - Phone:702-595-8309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV19048783473747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant