Provider Demographics
NPI:1487623179
Name:STOLWORTHY, HEATHER A (FNP)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:A
Last Name:STOLWORTHY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1574 S. LAKEMOOR WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-716-8069
Mailing Address - Fax:208-287-0423
Practice Address - Street 1:524 CLEVELAND BLVD.
Practice Address - Street 2:STE 110
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:573-814-1170
Practice Address - Fax:208-287-0423
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN23882363L00000X
IDNP610363L00000X
IDF0703081363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806691000Medicaid
ID1344246Medicare ID - Type Unspecified
ID806691000Medicaid