Provider Demographics
NPI:1922555358
Name:CHARLES, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:CHARLES
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:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-0686
Mailing Address - Country:US
Mailing Address - Phone:606-826-0257
Mailing Address - Fax:606-826-0206
Practice Address - Street 1:2135 HIGHWAY 1185
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-7968
Practice Address - Country:US
Practice Address - Phone:606-826-0257
Practice Address - Fax:606-826-0206
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist