Provider Demographics
NPI:1205514155
Name:HERON, CARLA (LE)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:HERON
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 MOUNT OLIVE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:AL
Mailing Address - Zip Code:35117-3800
Mailing Address - Country:US
Mailing Address - Phone:205-567-8376
Mailing Address - Fax:
Practice Address - Street 1:2722 MOUNT OLIVE RD
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:AL
Practice Address - Zip Code:35117-3800
Practice Address - Country:US
Practice Address - Phone:205-567-8376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL136485247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other