1609100635 NPI number — CHANDRA DENISE HEAVEN LPT

Table of content: CHANDRA DENISE HEAVEN LPT (NPI 1609100635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609100635 NPI number — CHANDRA DENISE HEAVEN LPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEAVEN
Provider First Name:
CHANDRA
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEAVEN
Provider Other First Name:
CHANDRA
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609100635
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2817 ROCK MERRITT AVE
Provider Second Line Business Mailing Address:
WOMACK ARMY MEDICAL CENTER
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28310-1700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-437-0444
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LIBERTY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28310-1700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-907-8922
Provider Business Practice Location Address Fax Number:
910-907-6069
Provider Enumeration Date:
09/23/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: 11396 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)