Provider Demographics
NPI:1598998536
Name:ANDERSON, HEATHER ALLISON (IDC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ALLISON
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 LAKE CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-7901
Mailing Address - Country:US
Mailing Address - Phone:858-663-7138
Mailing Address - Fax:
Practice Address - Street 1:1721 TAUSSIG BLVD
Practice Address - Street 2:JASON DUNHAM DDG 109 NAVAL STATION NORFOLK,
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511-2899
Practice Address - Country:US
Practice Address - Phone:858-663-7138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman