Healthcare Provider Details

I. General information

NPI: 1982480638
Provider Name (Legal Business Name): KAITLYN HEFFREN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 03/26/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 TULLAMORE AVE STE A
BLOOMINGTON IL
61704-9623
US

IV. Provider business mailing address

1603 TULLAMORE AVE STE A
BLOOMINGTON IL
61704-9623
US

V. Phone/Fax

Practice location:
  • Phone: 309-808-6407
  • Fax: 309-807-5478
Mailing address:
  • Phone: 309-808-6407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.027996
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: