Healthcare Provider Details

I. General information

NPI: 1043568553
Provider Name (Legal Business Name): ERLA PETRONETTE HEYNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 W STATE ST
ITHACA NY
14850-5474
US

IV. Provider business mailing address

3 BEECHNUT TER
ITHACA NY
14850-9611
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-7494
  • Fax:
Mailing address:
  • Phone: 607-277-2402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: