Healthcare Provider Details

I. General information

NPI: 1366166233
Provider Name (Legal Business Name): HEIDI CHAMBERLAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7108 S KANNER HWY
STUART FL
34997-7462
US

IV. Provider business mailing address

1121 S GENEVA DR
DEWITT MI
48820-9537
US

V. Phone/Fax

Practice location:
  • Phone: 772-349-6317
  • Fax:
Mailing address:
  • Phone: 517-648-5547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: