Healthcare Provider Details

I. General information

NPI: 1669818902
Provider Name (Legal Business Name): HEIDI LEIGH HAWKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEIDI LEIGH HOWARD

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

6125 E GATEWAY CT
BOISE ID
83716-9097
US

V. Phone/Fax

Practice location:
  • Phone: 208-331-9119
  • Fax:
Mailing address:
  • Phone: 208-331-9119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number03680908
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: