Provider Demographics
NPI:1063063162
Name:ACKERMAN, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 76
Mailing Address - Street 2:
Mailing Address - City:GRASSTON
Mailing Address - State:MN
Mailing Address - Zip Code:55030-0076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 OAK ST
Practice Address - Street 2:
Practice Address - City:GRASSTON
Practice Address - State:MN
Practice Address - Zip Code:55030
Practice Address - Country:US
Practice Address - Phone:707-867-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
344600000X
MN383233343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA700070400Medicaid