Healthcare Provider Details

I. General information

NPI: 1568823870
Provider Name (Legal Business Name): DIANA LYNN HEILIG D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 OSBORNE RD NE STE 255
FRIDLEY MN
55432-2768
US

IV. Provider business mailing address

4461 STATE ROUTE 159
CHILLICOTHEE OH
45601-8620
US

V. Phone/Fax

Practice location:
  • Phone: 763-786-6011
  • Fax: 763-236-2505
Mailing address:
  • Phone: 740-779-4900
  • Fax: 740-779-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number66180
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: