Healthcare Provider Details

I. General information

NPI: 1841703311
Provider Name (Legal Business Name): CYNTHIA A HEIDORN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CENTRAL SCHOOL RD
BELLEVILLE IL
62220-3265
US

IV. Provider business mailing address

105 W A ST
BELLEVILLE IL
62220-1326
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-5377
  • Fax:
Mailing address:
  • Phone: 618-234-4294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number041255265
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: