Provider Demographics
NPI:1669891784
Name:HEIMAN, ELIZABETH DAWN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DAWN
Last Name:HEIMAN
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 1:2450 DORA AVE
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4974
Mailing Address - Country:US
Mailing Address - Phone:352-434-4464
Mailing Address - Fax:352-434-3234
Practice Address - Street 1:2450 DORA AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4974
Practice Address - Country:US
Practice Address - Phone:352-434-4464
Practice Address - Fax:352-434-3234
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7472310400000X
FLAL7472305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012372200Medicaid