Provider Demographics
NPI:1326877515
Name:WALLACE, HEIDI CHRISTINE (ARNP, CNM)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:CHRISTINE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ARNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3958 BYRON AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-2870
Mailing Address - Country:US
Mailing Address - Phone:406-256-6148
Mailing Address - Fax:
Practice Address - Street 1:1400 E KINCAID ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-814-5892
Practice Address - Fax:360-848-4596
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAAP61581513367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife