Provider Demographics
NPI:1649430810
Name:HEINLEN, LATISHA DAWN (MD)
Entity type:Individual
Prefix:MRS
First Name:LATISHA
Middle Name:DAWN
Last Name:HEINLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:LATISHA
Other - Middle Name:DAWN
Other - Last Name:CAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6516 N OLIE AVE STE G
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-7399
Mailing Address - Country:US
Mailing Address - Phone:405-608-8060
Mailing Address - Fax:405-608-8070
Practice Address - Street 1:6516 N OLIE AVE STE G
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-7399
Practice Address - Country:US
Practice Address - Phone:405-608-8060
Practice Address - Fax:405-608-8070
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26317207RR0500X, 208M00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK26317OtherSTATE MEDICAL LICENSE