Healthcare Provider Details

I. General information

NPI: 1497296388
Provider Name (Legal Business Name): HEIDI GWIDT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 1/2 S. CTY. RD. X
MOSINEE WI
54455
US

IV. Provider business mailing address

2045 1/2 S. CTY RD. X
MOSINEE WI
54455
US

V. Phone/Fax

Practice location:
  • Phone: 715-347-7786
  • Fax:
Mailing address:
  • Phone: 715-347-7786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number152911-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: