Healthcare Provider Details

I. General information

NPI: 1477958254
Provider Name (Legal Business Name): TINA HECK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 MAPLE STREET
ISLAND POND VT
05846
US

IV. Provider business mailing address

PO BOX 425 82 MAPLE STREET
ISLAND POND VT
05846
US

V. Phone/Fax

Practice location:
  • Phone: 802-723-4300
  • Fax:
Mailing address:
  • Phone: 802-723-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0107042
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: