Provider Demographics
NPI:1871371336
Name:HECKATHORN, KACEY LAINE (RN, BSN, IBCLC)
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:LAINE
Last Name:HECKATHORN
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9925 MORGANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20664-2318
Mailing Address - Country:US
Mailing Address - Phone:240-320-4202
Mailing Address - Fax:
Practice Address - Street 1:9925 MORGANTOWN RD
Practice Address - Street 2:
Practice Address - City:NEWBURG
Practice Address - State:MD
Practice Address - Zip Code:20664-2318
Practice Address - Country:US
Practice Address - Phone:240-320-4202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDL-309407163WL0100X
MDR232561163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant