Basic Information
Provider Information
NPI: 1780242099
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HERRERA
FirstName: LUISA
MiddleName: FERNANDA
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 507 W 23RD ST # 2106
Address2:  
City: AUSTIN
State: TX
PostalCode: 787055215
CountryCode: US
TelephoneNumber: 9157049705
FaxNumber:  
Practice Location
Address1: 9390 RESEARCH BLVD # 100
Address2:  
City: AUSTIN
State: TX
PostalCode: 787596585
CountryCode: US
TelephoneNumber: 5123309520
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/01/2019
LastUpdateDate: 06/01/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X TXY    

No ID Information.


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