Healthcare Provider Details

I. General information

NPI: 1356112759
Provider Name (Legal Business Name): CAROLINE HEITZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 01/15/2024
Certification Date: 01/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

718 AMBLER LN
SALEM VA
24153-1105
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7631
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001292329
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: