Provider Demographics
NPI:1225335334
Name:HERIOT, ELLEN GWYN (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:GWYN
Last Name:HERIOT
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:MISS
Other - First Name:ELLEN
Other - Middle Name:GWYN
Other - Last Name:WEIDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6000 W HWY 98 NAVAL HOSPITAL
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32512-0003
Mailing Address - Country:US
Mailing Address - Phone:850-505-6412
Mailing Address - Fax:
Practice Address - Street 1:6000 W HWY 98 NAVAL HOSPITAL
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32512-0003
Practice Address - Country:US
Practice Address - Phone:850-505-6412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3601133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric