Healthcare Provider Details

I. General information

NPI: 1639755747
Provider Name (Legal Business Name): HEATHER BRUSS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER WHITING

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 30TH AVE STE 12
MOLINE IL
61265-5975
US

IV. Provider business mailing address

550 30TH AVE STE 12
MOLINE IL
61265-5975
US

V. Phone/Fax

Practice location:
  • Phone: 309-736-5568
  • Fax: 309-736-1152
Mailing address:
  • Phone: 309-736-5568
  • Fax: 309-736-1152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209022824
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA162114
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number209022824
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: