Provider Demographics
NPI:1588409783
Name:HEITMANN, IRINA NICOLE
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:NICOLE
Last Name:HEITMANN
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:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:MO
Mailing Address - Zip Code:63461-0208
Mailing Address - Country:US
Mailing Address - Phone:573-769-6166
Mailing Address - Fax:573-769-2356
Practice Address - Street 1:1219 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:MO
Practice Address - Zip Code:63461-1943
Practice Address - Country:US
Practice Address - Phone:573-769-6166
Practice Address - Fax:573-769-2356
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024025363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist