Provider Demographics
NPI:1467222331
Name:GENGNAGEL, HEATHER S (NP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:S
Last Name:GENGNAGEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:12750 SAINT FRANCIS DR STE 320
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-0264
Practice Address - Country:US
Practice Address - Phone:219-662-0077
Practice Address - Fax:219-662-9496
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28222842A363LF0000X
IN71014861A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily