Provider Demographics
NPI:1659504017
Name:FEARON, HEIDI ROSE (LAC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:ROSE
Last Name:FEARON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 MARLBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4711
Mailing Address - Country:US
Mailing Address - Phone:619-820-3146
Mailing Address - Fax:
Practice Address - Street 1:2635 CAMINO DEL RIO S STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3728
Practice Address - Country:US
Practice Address - Phone:619-818-4306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2016-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12958171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist