Healthcare Provider Details

I. General information

NPI: 1295736148
Provider Name (Legal Business Name): HEIDI BLAIR APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HAYS ST
TALLAHASSEE FL
32301-2699
US

IV. Provider business mailing address

225 MEMORIAL DR
BERLIN WI
54923-1243
US

V. Phone/Fax

Practice location:
  • Phone: 800-370-3651
  • Fax: 877-515-7147
Mailing address:
  • Phone: 920-361-1313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number112246-030
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2316-033
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9495268
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: