Provider Demographics
NPI:1437796950
Name:HEAVNER, PAMELA GAIL (LMT)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:GAIL
Last Name:HEAVNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9031 FASCINE CT
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-6570
Mailing Address - Country:US
Mailing Address - Phone:804-559-7990
Mailing Address - Fax:
Practice Address - Street 1:9291 LAUREL GROVE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2969
Practice Address - Country:US
Practice Address - Phone:804-559-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019003993225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0019003993OtherMEDICARE