MEDICARE: KOURTNEY LYNN HEITKAMP CNP

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	363L00000X	Nurse Practitioner	APRN.CNP.0028259	OH

General Provider Information

NPI Number	:	1558953943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOURTNEY LYNN HEITKAMP CNP

Provider Business Mailing Address
First Line	:	760 CLIFTON RD
Second Line	:
City	:	XENIA
State	:	OH
Zip	:	45385-9457
Country	:	US
Telephone Number	:	937-545-7905
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 YANKEE PARK PL
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-1868
Country	:	US
Telephone Number	:	937-439-4949
Fax Number	:	937-439-4948

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

Provider Enumeration Date	:	02/07/2021
Last Update Date	:	02/07/2021

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