1780730440 NPI number — NINA JEAN HERZOG ACNP-BC

Table of content: NINA JEAN HERZOG ACNP-BC (NPI 1780730440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780730440 NPI number — NINA JEAN HERZOG ACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERZOG
Provider First Name:
NINA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780730440
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8208 LOUISIANA BLVD NE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87113-1757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-858-1222
Provider Business Mailing Address Fax Number:
505-858-1224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8208 LOUISIANA BLVD NE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87113-1757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-858-1222
Provider Business Practice Location Address Fax Number:
505-858-1224
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  R49167 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: CNP01217 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: R49167 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R49167 . This is a "BNE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2006009954 . This is a "ANCC CERTIFICATION" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 87657317 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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