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General NPI Number Information
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NPI Number | 1457635633
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Entity Type | Individual
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Provider Name | HEIDI RUTH KALLESTAD ANP-C
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Gender | Female
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Dates
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Enumeration Date | 10/05/2011
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Last Update Date | 10/05/2011
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Provider Practice Location Address
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Address Line | 3050 REGENT BLVD STE 400
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City | IRVING
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State | TX
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Zip | 75063-5808
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Country | US
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Telephone | 214-689-8067
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Fax |
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Provider Business Mailing Address
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Address Line | 24306 E 3RD AVE
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City | LIBERTY LAKE
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State | WA
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Zip | 99019-9656
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Country | US
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Telephone | 206-999-8229
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 23483-A
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License Number State | ID
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