Healthcare Provider Details

I. General information

NPI: 1508248816
Provider Name (Legal Business Name): TAMARA HEFFERON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19420 N 59TH AVE
GLENDALE AZ
85308-6817
US

IV. Provider business mailing address

19420 N 59TH AVE
GLENDALE AZ
85308-6817
US

V. Phone/Fax

Practice location:
  • Phone: 866-901-0242
  • Fax:
Mailing address:
  • Phone: 866-901-0242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7917
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: