Basic Information
| Provider Information | |||||||||
| NPI: | 1194483248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTIERREZ HEREREA | ||||||||
| FirstName: | JURIELMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21895 CRESCENT PARK SQ APT 303 | ||||||||
| Address2: | |||||||||
| City: | BROADLANDS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201484435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5718884750 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2978 CENTREVILLE RD | ||||||||
| Address2: | |||||||||
| City: | HERNDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201716253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039345000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2021 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2306605958 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.