Provider Demographics
NPI:1407906571
Name:HEATLEY, LYNELL (OD)
Entity Type:Individual
Prefix:DR
First Name:LYNELL
Middle Name:
Last Name:HEATLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2111
Mailing Address - Street 2:
Mailing Address - City:OLYMPIC VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:96146-2111
Mailing Address - Country:US
Mailing Address - Phone:510-599-3837
Mailing Address - Fax:
Practice Address - Street 1:55 CRESCENT DR STE 10D
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-5511
Practice Address - Country:US
Practice Address - Phone:707-658-4988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2023-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8736152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10714Medicare UPIN
CAT10714Medicare UPIN