MEDICARE: ANDREW BRICE HEINECKE FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	5606726-4405	UT

General Provider Information

NPI Number	:	1447819974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW BRICE HEINECKE FNP-C

Provider Business Mailing Address
First Line	:	6807 S 3200 W
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84084-1828
Country	:	US
Telephone Number	:	801-350-1065
Fax Number	:

Provider Business Practice Location Address
First Line	:	6807 S 3200 W
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84084-1828
Country	:	US
Telephone Number	:	801-350-1065
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2019
Last Update Date	:	06/09/2019

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