Provider Demographics
NPI:1568122877
Name:DIXON, HEATHER MARIE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:DIXON
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 1:3213 FORMOSA AVE APT A
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-3953
Mailing Address - Country:US
Mailing Address - Phone:407-556-5693
Mailing Address - Fax:
Practice Address - Street 1:3213 FORMOSA AVE APT A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-3953
Practice Address - Country:US
Practice Address - Phone:407-556-5693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA95749225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist