Provider Demographics
NPI:1942702964
Name:RACINE, HEATHER NICOLE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:RACINE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3946 ICE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3946 ICE WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1018
Practice Address - Country:US
Practice Address - Phone:812-319-2519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002852A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer