Healthcare Provider Details

I. General information

NPI: 1184375958
Provider Name (Legal Business Name): CARLA HEFNER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1391 NW 136TH AVE
SUNRISE FL
33323-2800
US

IV. Provider business mailing address

1391 NW 136TH AVE
SUNRISE FL
33323-2800
US

V. Phone/Fax

Practice location:
  • Phone: 636-248-2567
  • Fax: 770-723-8676
Mailing address:
  • Phone: 636-248-2567
  • Fax: 770-723-8676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number106917
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: