Provider Demographics
NPI:1245416528
Name:ALLEN, HEATHER MICHELLE BEACH (LDO, ABOC, NCLEC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE BEACH
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LDO, ABOC, NCLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-1708
Mailing Address - Country:US
Mailing Address - Phone:919-567-0059
Mailing Address - Fax:919-567-0079
Practice Address - Street 1:504 BROAD ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-1708
Practice Address - Country:US
Practice Address - Phone:919-567-0059
Practice Address - Fax:919-567-0079
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1834156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician