Provider Demographics
NPI:1134316375
Name:HEAVNER, BETH ANN (MASTER OF AUDIOLOGY)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ANN
Last Name:HEAVNER
Suffix:
Gender:F
Credentials:MASTER OF AUDIOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 SE SUNNYSIDE RD
Mailing Address - Street 2:300-N
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5738
Mailing Address - Country:US
Mailing Address - Phone:503-659-5115
Mailing Address - Fax:
Practice Address - Street 1:10000 COORS BYP NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4040
Practice Address - Country:US
Practice Address - Phone:505-889-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM3838237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMAAA0152Medicare PIN