Provider Demographics
NPI:1033137450
Name:HEFFRON, MICHELLE LYNN (AHCNS)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LYNN
Last Name:HEFFRON
Suffix:
Gender:F
Credentials:AHCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11155 DUNN RD STE 204
Mailing Address - Street 2:STE 204
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6150
Mailing Address - Country:US
Mailing Address - Phone:314-355-3033
Mailing Address - Fax:314-355-0515
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6150
Practice Address - Country:US
Practice Address - Phone:314-355-3003
Practice Address - Fax:314-355-0515
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO124811364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428343404Medicaid
MOP00039293Medicare PIN
IL$$$$$$$$$001Medicaid
MO052010412Medicare PIN