Provider Demographics
NPI:1568677177
Name:HEINEMAN, MONICA LISABETH
Entity Type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:LISABETH
Last Name:HEINEMAN
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 1:615 VIOLA ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1746
Mailing Address - Country:US
Mailing Address - Phone:419-734-1310
Mailing Address - Fax:
Practice Address - Street 1:615 VIOLA ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1746
Practice Address - Country:US
Practice Address - Phone:419-734-1310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400426931104376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2357033Medicaid