Provider Demographics
NPI:1811498942
Name:HEFFINGTON, KELLY DIANE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:HEFFINGTON
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 1:1704 RANCH ROAD 3014
Mailing Address - Street 2:
Mailing Address - City:TOW
Mailing Address - State:TX
Mailing Address - Zip Code:78672-5170
Mailing Address - Country:US
Mailing Address - Phone:432-557-4910
Mailing Address - Fax:
Practice Address - Street 1:8001 S US HWY 75
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092
Practice Address - Country:US
Practice Address - Phone:903-532-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172817164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse