Provider Demographics
NPI:1669696993
Name:KINGSLEY, HEATHER (LAC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:KINGSLEY
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 1:34 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2713
Mailing Address - Country:US
Mailing Address - Phone:207-650-1530
Mailing Address - Fax:
Practice Address - Street 1:34 CARTER ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2713
Practice Address - Country:US
Practice Address - Phone:207-650-1530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC244171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME099144OtherBLUE CROSS BLUE SHIELD