Provider Demographics
NPI:1073041760
Name:HEISEL, AMANDA (NP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HEISEL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 CREEK BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:LABADIE
Mailing Address - State:MO
Mailing Address - Zip Code:63055-1121
Mailing Address - Country:US
Mailing Address - Phone:314-974-5017
Mailing Address - Fax:
Practice Address - Street 1:901 PATIENTS FIRST DR STE 3400
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4700
Practice Address - Country:US
Practice Address - Phone:636-239-5155
Practice Address - Fax:636-239-1478
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017010492363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology