Healthcare Provider Details

I. General information

NPI: 1225524903
Provider Name (Legal Business Name): HEATHER GAUDARD FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HEALTH PARK DRIVE
OWOSSO MI
48867-4886
US

IV. Provider business mailing address

200 HEALTH PARK DR
OWOSSO MI
48867-1291
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-8666
  • Fax: 989-725-1434
Mailing address:
  • Phone: 989-723-8666
  • Fax: 989-725-1434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704300581
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: