Healthcare Provider Details

I. General information

NPI: 1518575539
Provider Name (Legal Business Name): HEIDI ANNE EIKOM RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12033 AGENCY RD
PARKER AZ
85344-7718
US

IV. Provider business mailing address

12033 AGENCY RD
PARKER AZ
85344-7718
US

V. Phone/Fax

Practice location:
  • Phone: 928-669-2137
  • Fax: 928-669-3232
Mailing address:
  • Phone: 928-669-2137
  • Fax: 928-669-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SC1501X
TaxonomyCommunity Health/Public Health Clinical Nurse Specialist
License Number84620
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number757852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: