Provider Demographics
NPI:1174916217
Name:HERERIA, WENDY
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:HERERIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 DOVEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-4443
Mailing Address - Country:US
Mailing Address - Phone:209-684-8793
Mailing Address - Fax:209-951-0638
Practice Address - Street 1:650 DOVEWOOD ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-4443
Practice Address - Country:US
Practice Address - Phone:209-684-8793
Practice Address - Fax:209-951-0638
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA224434164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse