Healthcare Provider Details

I. General information

NPI: 1457506784
Provider Name (Legal Business Name): LYNN N. HEITZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16021 SOUTH HICKORY COURT
BELOIT WI
53511
US

IV. Provider business mailing address

W2968 MAIN ST
JUDA WI
53550-9525
US

V. Phone/Fax

Practice location:
  • Phone: 608-368-0328
  • Fax:
Mailing address:
  • Phone: 608-558-1936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number147572-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: