Healthcare Provider Details

I. General information

NPI: 1114594074
Provider Name (Legal Business Name): HEATHER JEANINE WALDEN ACUPUNCTURE PHYS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 06/09/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S KANNER HWY STE 3
STUART FL
34994-4600
US

IV. Provider business mailing address

2500 S KANNER HWY STE 3
STUART FL
34994-4600
US

V. Phone/Fax

Practice location:
  • Phone: 641-233-8919
  • Fax:
Mailing address:
  • Phone: 641-233-8919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number4151
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: