Provider Demographics
NPI:1265748297
Name:KING, HEATHER
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:CHANA
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:110 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-5439
Mailing Address - Country:US
Mailing Address - Phone:973-594-1919
Mailing Address - Fax:
Practice Address - Street 1:110 PARK AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-5439
Practice Address - Country:US
Practice Address - Phone:973-594-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ6851374J00000X
NJ25ME0067000367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No374J00000XNursing Service Related ProvidersDoula