Provider Demographics
NPI:1093310468
Name:DIOUBATE, HEATHER A
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:DIOUBATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5316 POPLARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-4438
Mailing Address - Country:US
Mailing Address - Phone:614-698-6396
Mailing Address - Fax:
Practice Address - Street 1:5316 POPLARWOOD RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-4438
Practice Address - Country:US
Practice Address - Phone:614-698-6396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086774Medicaid
OH2564489OtherDODD CONTRACT NUMBER