Healthcare Provider Details

I. General information

NPI: 1124433560
Provider Name (Legal Business Name): CAROLYN HEITHOLD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2341 MCCALLIE AVE SUITE 402
CHATTANOOGA TN
37404-3239
US

IV. Provider business mailing address

2341 MCCALLIE AVE SUITE 402
CHATTANOOGA TN
37404-3239
US

V. Phone/Fax

Practice location:
  • Phone: 423-698-3309
  • Fax: 423-624-6355
Mailing address:
  • Phone: 423-698-3309
  • Fax: 423-624-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN123800
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN19122
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: