Provider Demographics
NPI:1902305246
Name:HERBERT, MICHAELA ERMANIE
Entity Type:Individual
Prefix:MRS
First Name:MICHAELA
Middle Name:ERMANIE
Last Name:HERBERT
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 1:7720 GREENGAGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-7914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:837 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-6134
Practice Address - Country:US
Practice Address - Phone:817-305-4681
Practice Address - Fax:817-442-0748
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136409363LF0000X
TX935323363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care