Provider Demographics
NPI:1861936361
Name:HERRON, RICKY
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:HERRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 ROSA L PARKS BLVD APT 305
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37228-1242
Mailing Address - Country:US
Mailing Address - Phone:901-236-5455
Mailing Address - Fax:
Practice Address - Street 1:2333 ROSA L PARKS BLVD APT 305
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37228-1242
Practice Address - Country:US
Practice Address - Phone:901-236-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3397960Medicaid