Healthcare Provider Details

I. General information

NPI: 1093252504
Provider Name (Legal Business Name): HEATHER ORT APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2017
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 HOLY CROSS PKWY
MISHAWAKA IN
46545-1469
US

IV. Provider business mailing address

20149 INDIAN SCHOOL RD
LAKEVILLE IN
46536-9784
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-5000
  • Fax:
Mailing address:
  • Phone: 574-309-3884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number28147370A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71007551A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007551A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: