Provider Demographics
NPI:1396017463
Name:HEAVEN, GREGORY (LPN)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:HEAVEN
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:LEETONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44431-9601
Mailing Address - Country:US
Mailing Address - Phone:330-717-5502
Mailing Address - Fax:
Practice Address - Street 1:100 WILSON ST
Practice Address - Street 2:
Practice Address - City:LEETONIA
Practice Address - State:OH
Practice Address - Zip Code:44431-9601
Practice Address - Country:US
Practice Address - Phone:330-717-5502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN138531MIV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse