1700939683 NPI number — HEATHER R EARLE ARNP

Table of content: HEATHER R EARLE ARNP (NPI 1700939683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700939683 NPI number — HEATHER R EARLE ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EARLE
Provider First Name:
HEATHER
Provider Middle Name:
R
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:
BROCK
Provider Other First Name:
HEATHER
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700939683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1902 4TH ST STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA GRANDE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97850-2558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-663-0007
Provider Business Mailing Address Fax Number:
541-663-0010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1902 4TH ST STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-2558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-663-0007
Provider Business Practice Location Address Fax Number:
541-663-0010
Provider Enumeration Date:
01/22/2007

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: 363L00000X , with the licence number:  201900699NP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100166900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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