Provider Demographics
NPI:1033506167
Name:TEVICH, HEATHER (RN, AGPCNP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:TEVICH
Suffix:
Gender:F
Credentials:RN, AGPCNP
Other - Prefix:MISS
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:HINKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:351 W CAMDEN ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-7912
Mailing Address - Country:US
Mailing Address - Phone:414-852-5954
Mailing Address - Fax:
Practice Address - Street 1:351 W CAMDEN ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-7912
Practice Address - Country:US
Practice Address - Phone:414-852-5954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6263363LA2200X
WI135580163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse