Provider Demographics
NPI:1407157753
Name:HEADLY, ALLISON (PA-C)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:HEADLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:
Other - Last Name:BURNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2400 CORPORATE EXCHANGE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-7651
Mailing Address - Country:US
Mailing Address - Phone:614-505-7633
Mailing Address - Fax:
Practice Address - Street 1:4400 N HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-2635
Practice Address - Country:US
Practice Address - Phone:740-779-4598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant