Provider Demographics
NPI:1225202450
Name:O'NEILL-HEIDENTHAL, JUDY A
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:O'NEILL-HEIDENTHAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:A
Other - Last Name:O'NEILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 KINGSLEY LN
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4602
Mailing Address - Country:US
Mailing Address - Phone:757-889-4520
Mailing Address - Fax:757-889-5399
Practice Address - Street 1:150 KINGSLEY LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4602
Practice Address - Country:US
Practice Address - Phone:757-889-4520
Practice Address - Fax:757-889-5399
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA659843133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered