Healthcare Provider Details

I. General information

NPI: 1376126367
Provider Name (Legal Business Name): HEIDI L HANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 W MILLER ST
ORLANDO FL
32806-2032
US

IV. Provider business mailing address

92 W MILLER ST
ORLANDO FL
32806-2032
US

V. Phone/Fax

Practice location:
  • Phone: 321-842-4713
  • Fax: 321-841-5245
Mailing address:
  • Phone: 407-649-6907
  • Fax: 321-841-5245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116404
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: