Provider Demographics
NPI:1578912960
Name:ISOM, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:ISOM
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 1:3921 ASHMORE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-3809
Mailing Address - Country:US
Mailing Address - Phone:706-570-3797
Mailing Address - Fax:
Practice Address - Street 1:7101 HOFF ST
Practice Address - Street 2:BLDG 9240
Practice Address - City:FT. BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:706-544-1148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN284749163W00000X
GADH012267124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No163W00000XNursing Service ProvidersRegistered Nurse