Provider Demographics
NPI:1912416413
Name:STAFFORD, HEATHER ANN (NP-C)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:ANN
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:GRUNDHAUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:4433 E SWITZER WAY
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-3014
Mailing Address - Country:US
Mailing Address - Phone:208-871-3212
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID66533363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology