Healthcare Provider Details

I. General information

NPI: 1144399957
Provider Name (Legal Business Name): THERESA A. HEFFERNAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 NW 170TH ST
NORTH MIAMI BEACH FL
33169-5521
US

IV. Provider business mailing address

185 PENNY AVE
EAST DUNDEE IL
60118-1454
US

V. Phone/Fax

Practice location:
  • Phone: 305-654-3041
  • Fax:
Mailing address:
  • Phone: 847-836-7015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041-169856
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: