Provider Demographics
NPI:1316323033
Name:ANDERSON, HEATHER NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 KENNY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-4555
Mailing Address - Country:US
Mailing Address - Phone:937-533-3232
Mailing Address - Fax:
Practice Address - Street 1:506 KENNY RD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-4555
Practice Address - Country:US
Practice Address - Phone:937-533-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH014807225100000X
KS11-05131225100000X
MN10971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist