Provider Demographics
NPI:1962196170
Name:PENA, HEIDI SUE (APRN)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:SUE
Last Name:PENA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:SUE
Other - Last Name:GIPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5666 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2472
Mailing Address - Country:US
Mailing Address - Phone:815-226-2000
Mailing Address - Fax:
Practice Address - Street 1:5666 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2472
Practice Address - Country:US
Practice Address - Phone:815-226-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027609363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner