Provider Demographics
NPI:1386137453
Name:GOUGH, HEATHER (RN)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GOUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3244 E MORENCI RD
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-4552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3244 E MORENCI RD
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-4552
Practice Address - Country:US
Practice Address - Phone:833-243-2780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001259720163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health