Provider Demographics
NPI:1821793415
Name:HERON, KEKA
Entity Type:Individual
Prefix:
First Name:KEKA
Middle Name:
Last Name:HERON
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 1:2779 KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4112
Mailing Address - Country:US
Mailing Address - Phone:404-427-5843
Mailing Address - Fax:
Practice Address - Street 1:3845 N DRUID HILLS RD STE 208
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3005
Practice Address - Country:US
Practice Address - Phone:404-427-5843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management