Healthcare Provider Details

I. General information

NPI: 1386973741
Provider Name (Legal Business Name): HEATHER MARIE LANDRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER MARIE CHANG

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 10/07/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S STATE ST
DOVER DE
19901-3530
US

IV. Provider business mailing address

640 S. STATE ST MAIL CODE 3055
DOVER DE
19901-3530
US

V. Phone/Fax

Practice location:
  • Phone: 302-430-5746
  • Fax: 302-430-5507
Mailing address:
  • Phone: 302-430-5746
  • Fax: 302-430-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR177819
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberL6-0A00787
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: