1245563782 NPI number — HEATHER MAUCK ARNP

Table of content: HEATHER MAUCK ARNP (NPI 1245563782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245563782 NPI number — HEATHER MAUCK ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAUCK
Provider First Name:
HEATHER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245563782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 703
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOXIE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67740-0703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-657-1434
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
917 PINE AVE STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOXIE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67740-4216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-677-3930
Provider Business Practice Location Address Fax Number:
785-677-3931
Provider Enumeration Date:
09/16/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  5374988 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 5374988122 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WP0808X , with the licence number: 5374988 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: D200635510 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".