Provider Demographics
NPI:1669024162
Name:HEINZE, ERICA JADE (IBCLC)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:JADE
Last Name:HEINZE
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 LAKEVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3216
Mailing Address - Country:US
Mailing Address - Phone:801-648-2849
Mailing Address - Fax:
Practice Address - Street 1:150 S 600 E STE 2C
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2098
Practice Address - Country:US
Practice Address - Phone:801-410-4204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-157762174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN