Provider Demographics
NPI:1902475288
Name:HEREDIA, STELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:STELLA
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:866-234-8534
Mailing Address - Fax:
Practice Address - Street 1:109 W WALL ST
Practice Address - Street 2:
Practice Address - City:FROSTPROOF
Practice Address - State:FL
Practice Address - Zip Code:33843-2043
Practice Address - Country:US
Practice Address - Phone:866-234-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22443207Q00000X
FLACN1393208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine