Healthcare Provider Details

I. General information

NPI: 1255743415
Provider Name (Legal Business Name): KATHRYN HEGGBLOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1452 N US HIGHWAY 1
ORMOND BEACH FL
32174-6638
US

IV. Provider business mailing address

1452 N US HIGHWAY 1
ORMOND BEACH FL
32174-6638
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-1250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: