Healthcare Provider Details

I. General information

NPI: 1609223742
Provider Name (Legal Business Name): BECKY HEIDOTTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W 10TH ST
ROLLA MO
65401-2905
US

IV. Provider business mailing address

10 ELDORADO DR
FLORISSANT MO
63031-5317
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-7879
  • Fax:
Mailing address:
  • Phone: 314-513-8145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2016012209
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: