Healthcare Provider Details

I. General information

NPI: 1457170615
Provider Name (Legal Business Name): HEATHER HERBOLD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 DELAWARE AVE
FOUNTAIN HILL PA
18015-1108
US

IV. Provider business mailing address

2624 27TH ST SW
ALLENTOWN PA
18103-7210
US

V. Phone/Fax

Practice location:
  • Phone: 717-855-7621
  • Fax:
Mailing address:
  • Phone: 717-855-7621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberSP030930
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License NumberRN712920
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: