Provider Demographics
NPI:1043426604
Name:HEIDRICH, MARY CAROL (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAROL
Last Name:HEIDRICH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 BEECH DR
Mailing Address - Street 2:
Mailing Address - City:TAYLOR MILL
Mailing Address - State:KY
Mailing Address - Zip Code:41015-2103
Mailing Address - Country:US
Mailing Address - Phone:859-815-1098
Mailing Address - Fax:859-815-1094
Practice Address - Street 1:2014 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41014-1530
Practice Address - Country:US
Practice Address - Phone:859-815-1098
Practice Address - Fax:859-815-1094
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1027631171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator