Healthcare Provider Details

I. General information

NPI: 1619365368
Provider Name (Legal Business Name): JAIMIE LYNN HECKMAN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 BROADCASTING RD
WYOMISSING PA
19610-3222
US

IV. Provider business mailing address

715 RIDGE RD
SHOEMAKERSVILLE PA
19555-9037
US

V. Phone/Fax

Practice location:
  • Phone: 484-336-8477
  • Fax:
Mailing address:
  • Phone: 484-336-8477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WU0100X
TaxonomyUrology Registered Nurse
License NumberRN521585L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP015618
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: