Healthcare Provider Details

I. General information

NPI: 1568733541
Provider Name (Legal Business Name): HEIDI KRISTINA MILLER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEIDI MACKERT

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 W WAVERLY ST
MORRIS IL
60450-1334
US

IV. Provider business mailing address

725 SCHOOL ST STE A
MORRIS IL
60450-1207
US

V. Phone/Fax

Practice location:
  • Phone: 815-941-0441
  • Fax: 815-941-0472
Mailing address:
  • Phone: 815-941-9124
  • Fax: 815-941-4363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209021634
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238.000315
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number238.000315
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: