Provider Demographics
NPI:1417543190
Name:WALDROUP, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WALDROUP
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 1:2700 E SUNSET RD STE 17
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 E SUNSET RD STE 17
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3508
Practice Address - Country:US
Practice Address - Phone:702-476-8809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK6733493Medicaid