Provider Demographics
NPI:1992096804
Name:WITHEY, HEIDI LYNN (LAC, EAMP)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYNN
Last Name:WITHEY
Suffix:
Gender:F
Credentials:LAC, EAMP
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:LYNN
Other - Last Name:DE JONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC, EAMP
Mailing Address - Street 1:310 S. 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362
Mailing Address - Country:US
Mailing Address - Phone:509-525-9081
Mailing Address - Fax:
Practice Address - Street 1:310 S. 3RD AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-525-9081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR154420171100000X
WAAC60248752171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist