Provider Demographics
NPI:1033626262
Name:SAN JUAN, HEATHER ANN (APN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:SAN JUAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 S POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-4061
Mailing Address - Country:US
Mailing Address - Phone:630-217-9620
Mailing Address - Fax:
Practice Address - Street 1:613 S POPLAR AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-4061
Practice Address - Country:US
Practice Address - Phone:630-217-9620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016722363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.016722OtherIDFPR