Provider Demographics
NPI:1275366213
Name:ANDERSON NICHOLSON, HEATHER SIMONE MALISSA SUE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:SIMONE MALISSA SUE
Last Name:ANDERSON NICHOLSON
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 1:2142 E ELECTRA LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-8608
Mailing Address - Country:US
Mailing Address - Phone:602-538-3801
Mailing Address - Fax:
Practice Address - Street 1:2142 E ELECTRA LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-8608
Practice Address - Country:US
Practice Address - Phone:602-538-3801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9315848253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care