Healthcare Provider Details

I. General information

NPI: 1770207664
Provider Name (Legal Business Name): MRS. MAUREEN ANN HEITMEIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 AVENUE O
FORT MADISON IA
52627-9601
US

IV. Provider business mailing address

1710 KOESTNER ST
BURLINGTON IA
52601-7007
US

V. Phone/Fax

Practice location:
  • Phone: 319-376-2134
  • Fax:
Mailing address:
  • Phone: 309-313-4783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA171401
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: