Healthcare Provider Details

I. General information

NPI: 1841804234
Provider Name (Legal Business Name): MARIEKE NMN HEATWOLE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 ARCTIC BLVD STE 104
ANCHORAGE AK
99503-5702
US

IV. Provider business mailing address

205 E DIMOND BLVD
ANCHORAGE AK
99515-1909
US

V. Phone/Fax

Practice location:
  • Phone: 907-677-5910
  • Fax: 907-600-7711
Mailing address:
  • Phone: 907-677-5910
  • Fax: 907-600-7711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number118269
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number165235
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number118269
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: