Healthcare Provider Details

I. General information

NPI: 1144712654
Provider Name (Legal Business Name): MARY HEATON CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 NEW BERN AVE STE 102
RALEIGH NC
27610-2989
US

IV. Provider business mailing address

3031 NEW BERN AVE STE 102
RALEIGH NC
27610-2989
US

V. Phone/Fax

Practice location:
  • Phone: 919-231-3132
  • Fax:
Mailing address:
  • Phone: 919-231-3132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: