Provider Demographics
NPI:1336595305
Name:CAMERON, HEIDI (LAC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:CAMERON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15005 FORT CAMPBELL BLVD.
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42262
Mailing Address - Country:US
Mailing Address - Phone:512-534-5404
Mailing Address - Fax:
Practice Address - Street 1:2889B IDAHO AVENUE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:512-534-5404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAC109171100000X
TNACU0000000281171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist