1134498132 NPI number — MRS. KELLI NICOLE HEER PA-C

Table of content: MRS. KELLI NICOLE HEER PA-C (NPI 1134498132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134498132 NPI number — MRS. KELLI NICOLE HEER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEER
Provider First Name:
KELLI
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1134498132
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2505 HARRISON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PANAMA CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32405-4464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-233-3376
Provider Business Mailing Address Fax Number:
850-522-8354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 WESTSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36303-1908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-231-3376
Provider Business Practice Location Address Fax Number:
850-522-8354
Provider Enumeration Date:
12/20/2011

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: 363AS0400X , with the licence number:  PA 803 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA.803 . This is a "AL PHYSICIAN ASSISTANT" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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