Provider Demographics
NPI:1104916956
Name:HEASTON, SONDRA DIANE (NP-C)
Entity type:Individual
Prefix:
First Name:SONDRA
Middle Name:DIANE
Last Name:HEASTON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 N 1450 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3714
Mailing Address - Country:US
Mailing Address - Phone:801-377-1298
Mailing Address - Fax:
Practice Address - Street 1:3215 VALLEY ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-4217
Practice Address - Country:US
Practice Address - Phone:801-466-3102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT217181-4405363LF0000X
UT217181-8900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily