Healthcare Provider Details

I. General information

NPI: 1073593737
Provider Name (Legal Business Name): BEVERLY ANN HEINKING D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PINEWOOD DR SW
LIVE OAK FL
32064-4029
US

IV. Provider business mailing address

300 PINEWOOD DR SW
LIVE OAK FL
32064-4029
US

V. Phone/Fax

Practice location:
  • Phone: 386-362-1014
  • Fax: 386-362-5076
Mailing address:
  • Phone: 386-362-1014
  • Fax: 386-362-5076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS5866
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9F01
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: