Basic Information
| Provider Information | |||||||||
| NPI: | 1366787772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEERBOTH | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | NICOLE DELGADO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DELGADO | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1452 ALEGRIA LOOP | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951284559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4086664146 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5671 SANTA TERESA BLVD | ||||||||
| Address2: | 105 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951236512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082842280 | ||||||||
| FaxNumber: | 4087540450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2012 | ||||||||
| LastUpdateDate: | 12/11/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | 779153 | CA | Y | Nursing Service Providers | Registered Nurse | Pediatrics |
No ID Information.