1487623179 NPI number — MS. HEATHER A STOLWORTHY FNP

Table of content: MS. HEATHER A STOLWORTHY FNP (NPI 1487623179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487623179 NPI number — MS. HEATHER A STOLWORTHY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOLWORTHY
Provider First Name:
HEATHER
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1487623179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1574 S. LAKEMOOR WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-716-8069
Provider Business Mailing Address Fax Number:
208-287-0423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
524 CLEVELAND BLVD.
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-814-1170
Provider Business Practice Location Address Fax Number:
208-287-0423
Provider Enumeration Date:
03/15/2006

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:  N23882 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: NP610 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: F0703081 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 806691000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com