Provider Demographics
NPI:1528574704
Name:HERON, NINA JUNE (LMT)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:JUNE
Last Name:HERON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:JUNE
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10325 COUNTY ROAD 250
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-3115
Mailing Address - Country:US
Mailing Address - Phone:970-238-0924
Mailing Address - Fax:
Practice Address - Street 1:1032 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5124
Practice Address - Country:US
Practice Address - Phone:970-382-8332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-25
Last Update Date:2017-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT000478225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist