Provider Demographics
NPI:1497029870
Name:HEAVNER, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:HEAVNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14546 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5468
Mailing Address - Country:US
Mailing Address - Phone:904-352-2466
Mailing Address - Fax:904-352-2472
Practice Address - Street 1:14546 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5468
Practice Address - Country:US
Practice Address - Phone:904-352-2466
Practice Address - Fax:904-352-2472
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1791572363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health