Provider Demographics
NPI:1689802068
Name:MANCEBO, HEATHER MARIE GOODWIN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE GOODWIN
Last Name:MANCEBO
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 1:296 HAMBY LN
Mailing Address - Street 2:
Mailing Address - City:SOCIAL CIRCLE
Mailing Address - State:GA
Mailing Address - Zip Code:30025-4851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2130 W SPRING STREET, SUITE 300
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655
Practice Address - Country:US
Practice Address - Phone:678-905-9121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282980207Q00000X
MDD0074885207Q00000X
GA96784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD149619Medicare UPIN
MD945LMedicare PIN