Provider Demographics
NPI:1043528649
Name:HEAVNER, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:HEAVNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 GAFFNEY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1060 GAFFNEY RD
Practice Address - Street 2:
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-5001
Practice Address - Country:US
Practice Address - Phone:907-361-5692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK31450163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health