Provider Demographics
NPI:1427772516
Name:HIMMELBERG, HARLIE
Entity type:Individual
Prefix:
First Name:HARLIE
Middle Name:
Last Name:HIMMELBERG
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 1:1026 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2902
Mailing Address - Country:US
Mailing Address - Phone:402-621-0599
Mailing Address - Fax:
Practice Address - Street 1:1026 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2902
Practice Address - Country:US
Practice Address - Phone:307-333-0002
Practice Address - Fax:307-202-5112
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA1095363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program