Provider Demographics
NPI:1801612353
Name:HEATHORN, ALEXA
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:HEATHORN
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 1:15 SHADOW OAK RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-2339
Mailing Address - Country:US
Mailing Address - Phone:925-766-0754
Mailing Address - Fax:
Practice Address - Street 1:15 SHADOW OAK RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-2339
Practice Address - Country:US
Practice Address - Phone:925-766-0754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist