Provider Demographics
NPI:1043616311
Name:CARLSON, HEATHER LEILANIA (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEILANIA
Last Name:CARLSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LEILANIA
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:351 W CAMDEN ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-7912
Mailing Address - Country:US
Mailing Address - Phone:410-625-2200
Mailing Address - Fax:
Practice Address - Street 1:351 W CAMDEN ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-7912
Practice Address - Country:US
Practice Address - Phone:410-625-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191800363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology