Provider Demographics
NPI:1558135319
Name:HEISER, KRISTA DAWNELLE
Entity Type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:DAWNELLE
Last Name:HEISER
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 1:620 23RD ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-3878
Mailing Address - Country:US
Mailing Address - Phone:234-281-8794
Mailing Address - Fax:
Practice Address - Street 1:620 23RD ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-3878
Practice Address - Country:US
Practice Address - Phone:234-281-8794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRP608396172A00000X
253Z00000X, 261QA0600X, 3747P1801X, 251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
No172A00000XOther Service ProvidersDriver
No253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant