Healthcare Provider Details

I. General information

NPI: 1386469294
Provider Name (Legal Business Name): PAYTON HEIDER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8426 STACY DR
FREDONIA WI
53021-9643
US

IV. Provider business mailing address

8426 STACY DR
FREDONIA WI
53021-9643
US

V. Phone/Fax

Practice location:
  • Phone: 262-675-4282
  • Fax:
Mailing address:
  • Phone: 262-675-4282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1113810-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: