Healthcare Provider Details

I. General information

NPI: 1578741013
Provider Name (Legal Business Name): CARLA R HEISER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 E CARMEL DR SUITE 154
CARMEL IN
46032-2812
US

IV. Provider business mailing address

6400 INDUSTRIAL LOOP
GREENDALE WI
53129-2452
US

V. Phone/Fax

Practice location:
  • Phone: 317-753-5694
  • Fax: 866-315-7638
Mailing address:
  • Phone: 414-423-4100
  • Fax: 144-234-1344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164003355
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: