Provider Demographics
NPI:1962118695
Name:HEACOCK, KATHRYN JANICE (DNP, APRN-CNS, CRNP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JANICE
Last Name:HEACOCK
Suffix:
Gender:F
Credentials:DNP, APRN-CNS, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 NABBS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-8435
Mailing Address - Country:US
Mailing Address - Phone:919-593-4201
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1590
Practice Address - Country:US
Practice Address - Phone:410-328-4622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCS00199364SA2100X
MDR226946363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care