Healthcare Provider Details

I. General information

NPI: 1669162442
Provider Name (Legal Business Name): HEATHER KATHLEEN EDSTROM WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4751 N 15TH ST
PHOENIX AZ
85014-3707
US

IV. Provider business mailing address

2315 N LANTERN LN
FLAGSTAFF AZ
86001-1134
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-4212
  • Fax:
Mailing address:
  • Phone: 708-921-6163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number336154
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: