Provider Demographics
NPI:1740809433
Name:HERON, KENOVIAH (DO)
Entity type:Individual
Prefix:MS
First Name:KENOVIAH
Middle Name:
Last Name:HERON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 24TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-3311
Mailing Address - Country:US
Mailing Address - Phone:727-542-5763
Mailing Address - Fax:
Practice Address - Street 1:1800 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7521
Practice Address - Country:US
Practice Address - Phone:727-542-5763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program