Provider Demographics
NPI:1457839912
Name:JIMENEZ, HEATHER MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ELDORADO ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-3407
Mailing Address - Country:US
Mailing Address - Phone:315-400-9917
Mailing Address - Fax:
Practice Address - Street 1:114 ELDORADO ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-3407
Practice Address - Country:US
Practice Address - Phone:315-400-9917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264632-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse