Healthcare Provider Details

I. General information

NPI: 1033028675
Provider Name (Legal Business Name): STEPHANIE MARIE LIEDHOLM-HEINING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11513 HANNAH DR
CONIFER CO
80433-7531
US

IV. Provider business mailing address

11513 HANNAH DR
CONIFER CO
80433-7531
US

V. Phone/Fax

Practice location:
  • Phone: 612-247-2142
  • Fax:
Mailing address:
  • Phone: 612-247-2142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number126562-4
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.0127536
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: