Provider Demographics
NPI:1356729826
Name:HEINS, CARROLL-ANNE
Entity type:Individual
Prefix:
First Name:CARROLL-ANNE
Middle Name:
Last Name:HEINS
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 1:3600 BROADWAY STE 43
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5730
Mailing Address - Country:US
Mailing Address - Phone:510-752-1933
Mailing Address - Fax:510-752-1571
Practice Address - Street 1:3600 BROADWAY STE 43
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5730
Practice Address - Country:US
Practice Address - Phone:510-752-1933
Practice Address - Fax:510-752-1571
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
CA20A17364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program