Healthcare Provider Details

I. General information

NPI: 1669162442
Provider Name (Legal Business Name): HEATHER KATHLEEN EDSTROM WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 S LAPEER RD
LAKE ORION MI
48360-1437
US

IV. Provider business mailing address

1428 S LAPEER RD
LAKE ORION MI
48360-1437
US

V. Phone/Fax

Practice location:
  • Phone: 248-693-0543
  • Fax:
Mailing address:
  • Phone: 248-845-4237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number4704367878
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: