Provider Demographics
NPI:1184235236
Name:HERZOG, KATHERINE VICTORIA (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:VICTORIA
Last Name:HERZOG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28200 HWY 189 STE 02-220, #761
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-9700
Mailing Address - Country:US
Mailing Address - Phone:714-398-5246
Mailing Address - Fax:
Practice Address - Street 1:28200 HIGHWAY 189 STE 2-220
Practice Address - Street 2:
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-9700
Practice Address - Country:US
Practice Address - Phone:714-398-5246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10015762363LF0000X
CA95034447363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily