Provider Demographics
NPI:1578741013
Name:HEISER, CARLA R
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:R
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 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-423-4100
Mailing Address - Fax:144-234-1344
Practice Address - Street 1:484 E CARMEL DR
Practice Address - Street 2:SUITE 154
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2812
Practice Address - Country:US
Practice Address - Phone:317-753-5694
Practice Address - Fax:866-315-7638
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164003355133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164003355OtherNUTRITIONAL DIETITIAN