Basic Information
| Provider Information | |||||||||
| NPI: | 1730152919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERIOT | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 551420 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333551420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 8558514405 | ||||||||
| Practice Location | |||||||||
| Address1: | 4725 N. FEDERAL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333084603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547718000 | ||||||||
| FaxNumber: | 9547763270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP927462 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | G1492 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 306481600 | 05 | FL | MEDICAID | G1492 | 01 | BCBS PROVIDER # | OTHER |