Provider Demographics
NPI:1720617236
Name:PHILLIPS, HEIDI SUZANNE (MSN APRN CNM IBCLC)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:SUZANNE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MSN APRN CNM IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 MARINE DR
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3808
Mailing Address - Country:US
Mailing Address - Phone:503-468-0650
Mailing Address - Fax:503-376-6716
Practice Address - Street 1:1406 MARINE DR
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3808
Practice Address - Country:US
Practice Address - Phone:503-468-0650
Practice Address - Fax:503-376-6716
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COL-165889163WL0100X
COAPN.0995468-CNM367A00000X
OR202104538NP-PP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant