Healthcare Provider Details

I. General information

NPI: 1790675262
Provider Name (Legal Business Name): HEATHER BRECKENRIDGE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 N 4TH ST STE 6
FLAGSTAFF AZ
86004-1812
US

IV. Provider business mailing address

2615 N 4TH ST STE 6
FLAGSTAFF AZ
86004-1812
US

V. Phone/Fax

Practice location:
  • Phone: 928-699-3266
  • Fax:
Mailing address:
  • Phone: 928-549-0730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number339539RNP
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code163WF0300X
TaxonomyFlight Registered Nurse
License NumberRN171832
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: