Healthcare Provider Details

I. General information

NPI: 1790869097
Provider Name (Legal Business Name): NANCY J. HEFFERNAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. NANCY WARD

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W BENJAMIN HOLT DR D-4
STOCKTON CA
95207-3958
US

IV. Provider business mailing address

1691 THE ALAMEDA
SAN JOSE CA
95126-2203
US

V. Phone/Fax

Practice location:
  • Phone: 209-472-7569
  • Fax: 209-477-1065
Mailing address:
  • Phone: 408-795-3619
  • Fax: 408-287-0405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number658516
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number19052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: