Basic Information
Provider Information | |||||||||
NPI: | 1942284492 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIXON | ||||||||
FirstName: | HEIDI | ||||||||
MiddleName: | LATRELL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 851 TRAFALGAR COURT | ||||||||
Address2: | SUITE 200E | ||||||||
City: | MAITLAND | ||||||||
State: | FL | ||||||||
PostalCode: | 32751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4076670444 | ||||||||
FaxNumber: | 4076674338 | ||||||||
Practice Location | |||||||||
Address1: | 110 29TH AVE N STE 202 | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372031448 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153274304 | ||||||||
FaxNumber: | 6153277940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2005 | ||||||||
LastUpdateDate: | 07/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 17717 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | ARNP9207469 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 306327500 | 05 | FL |   | MEDICAID |