1518264076 NPI number — NATALIE HERRICK

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518264076 NPI number — NATALIE HERRICK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERRICK
Provider First Name:
NATALIE
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:
1518264076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 SUNRISE BLVD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEBARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-887-4254
Provider Business Mailing Address Fax Number:
724-626-2785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
366 E. GRAVES AVE.
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
ORANGE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-986-4589
Provider Business Practice Location Address Fax Number:
407-890-6763
Provider Enumeration Date:
02/18/2011

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: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111026500 . 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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