Healthcare Provider Details

I. General information

NPI: 1912906470
Provider Name (Legal Business Name): HEIDI JO CARLSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 OAK ST / 6579
BROOKINGS OR
97415-0285
US

IV. Provider business mailing address

PO BOX 6579 446 OAK ST / 6579
BROOKINGS OR
97415-0285
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-8898
  • Fax: 541-412-7420
Mailing address:
  • Phone: 541-412-8898
  • Fax: 541-412-7420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200150156
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: