Provider Demographics
NPI:1851599096
Name:WILLS HEASTON, LINDA AILEEN
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:AILEEN
Last Name:WILLS HEASTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AILEEN
Other - Middle Name:W
Other - Last Name:HEASTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:10301 DAWSONS CREEK BLVD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1955
Mailing Address - Country:US
Mailing Address - Phone:260-489-3996
Mailing Address - Fax:260-497-8612
Practice Address - Street 1:10301 DAWSONS CREEK BLVD
Practice Address - Street 2:SUITE 2A
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1955
Practice Address - Country:US
Practice Address - Phone:260-489-3996
Practice Address - Fax:260-497-8612
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002550B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4366240001Medicare ID - Type Unspecified
IN667490Medicare UPIN