Healthcare Provider Details

I. General information

NPI: 1407331937
Provider Name (Legal Business Name): NICOLE LAUREN HEENEY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE LAUREN NAHIGIAN

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MARK WEST SPRINGS RD
SANTA ROSA CA
95403-1436
US

IV. Provider business mailing address

16251 MAIN ST
GUERNEVILLE CA
95446-8300
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-4340
  • Fax:
Mailing address:
  • Phone: 415-816-7994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number79034
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number11330
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: