Provider Demographics
NPI:1790828770
Name:HEADEN, VIVIAN MARIE
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:MARIE
Last Name:HEADEN
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 1:1109 SUNRISE PL
Mailing Address - Street 2:
Mailing Address - City:SILER CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27344-9442
Mailing Address - Country:US
Mailing Address - Phone:919-663-1891
Mailing Address - Fax:
Practice Address - Street 1:209 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:SILER CITY
Practice Address - State:NC
Practice Address - Zip Code:27344-3429
Practice Address - Country:US
Practice Address - Phone:919-663-1366
Practice Address - Fax:919-663-1369
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3408022251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408022Medicaid