1104436963 NPI number — CASSANDRA HERT

Table of content: CASSANDRA HERT (NPI 1104436963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104436963 NPI number — CASSANDRA HERT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERT
Provider First Name:
CASSANDRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1104436963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1234 WETLAND RIDGE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLEBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32068-8746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-632-8775
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13738 ALESBURY CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32224-2236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-502-8502
Provider Business Practice Location Address Fax Number:
904-701-6264
Provider Enumeration Date:
08/06/2020

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: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 107564600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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