Healthcare Provider Details

I. General information

NPI: 1215975313
Provider Name (Legal Business Name): CHRISTINE L HERITAGE NMNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 DEADMOND FERRY RD
SPRINGFIELD OR
97477-9406
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT 358
VANCOUVER WA
98683-9324
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-7750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number089006318N5
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: