Healthcare Provider Details

I. General information

NPI: 1265240642
Provider Name (Legal Business Name): HEIDI COSEY RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 BECK AVE
FAIRFIELD CA
94533-6804
US

IV. Provider business mailing address

275 BECK AVE
FAIRFIELD CA
94533-6804
US

V. Phone/Fax

Practice location:
  • Phone: 707-784-8070
  • Fax: 707-438-2500
Mailing address:
  • Phone: 707-784-8070
  • Fax: 707-438-2500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95264793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: