Healthcare Provider Details

I. General information

NPI: 1639607781
Provider Name (Legal Business Name): HEATHER LEE POLLET APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W 4TH ST
COFFEYVILLE KS
67337-3306
US

IV. Provider business mailing address

RR 1 BOX 207-50
S COFFEYVILLE OK
74072-9754
US

V. Phone/Fax

Practice location:
  • Phone: 620-252-1639
  • Fax: 620-252-1541
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number14-88134-091
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-77703
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: