Provider Demographics
NPI:1790125235
Name:HEATON, SHORI A (PDHA II)
Entity Type:Individual
Prefix:
First Name:SHORI
Middle Name:A
Last Name:HEATON
Suffix:
Gender:F
Credentials:PDHA II
Other - Prefix:
Other - First Name:SHORI
Other - Middle Name:A
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PDHA II
Mailing Address - Street 1:131 1ST AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:HAINES
Mailing Address - State:AK
Mailing Address - Zip Code:99827
Mailing Address - Country:US
Mailing Address - Phone:907-766-6338
Mailing Address - Fax:907-766-2581
Practice Address - Street 1:131 1ST AVE SOUTH
Practice Address - Street 2:
Practice Address - City:HAINES
Practice Address - State:AK
Practice Address - Zip Code:99827
Practice Address - Country:US
Practice Address - Phone:907-766-6338
Practice Address - Fax:907-766-2581
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker