Provider Demographics
NPI:1184217564
Name:DIZON, HEIDE MARIE (RN)
Entity Type:Individual
Prefix:
First Name:HEIDE MARIE
Middle Name:
Last Name:DIZON
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 1:12014 WYNNFIELD LAKES CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4234
Mailing Address - Country:US
Mailing Address - Phone:904-316-5865
Mailing Address - Fax:
Practice Address - Street 1:12014 WYNNFIELD LAKES CIR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-4234
Practice Address - Country:US
Practice Address - Phone:904-316-5865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility