Healthcare Provider Details

I. General information

NPI: 1982807913
Provider Name (Legal Business Name): LISA G HEIDEMANN R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 S LAPEER
OXFORD MI
48173
US

IV. Provider business mailing address

1450 S LAPEER
OXFORD MI
48173
US

V. Phone/Fax

Practice location:
  • Phone: 248-969-9320
  • Fax:
Mailing address:
  • Phone: 248-969-9320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704140714
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: