Provider Demographics
NPI:1437122371
Name:HEISEL, AMY L (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:HEISEL
Suffix:
Gender:F
Credentials:MD
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-212-5025
Mailing Address - Fax:859-212-4432
Practice Address - Street 1:7370 TURFWAY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4895
Practice Address - Country:US
Practice Address - Phone:859-212-5025
Practice Address - Fax:859-212-4432
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067119208000000X
KY30844208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50024406OtherPASSPORT MEDICAID
KY64982580Medicaid
OH0052796Medicaid
OH0052796Medicaid