Provider Demographics
NPI:1871064592
Name:HEAVENS, KRISTEN RUTH (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RUTH
Last Name:HEAVENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BRIARCLIFF DR S UNIT 2
Mailing Address - Street 2:
Mailing Address - City:OSSINING
Mailing Address - State:NY
Mailing Address - Zip Code:10562-2339
Mailing Address - Country:US
Mailing Address - Phone:860-485-3197
Mailing Address - Fax:
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:254-287-4305
Practice Address - Fax:254-553-3063
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY024362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant