Provider Demographics
NPI:1073705448
Name:HEAP, ELIZABETH (RN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HEAP
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:SWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:151 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-2141
Mailing Address - Country:US
Mailing Address - Phone:435-843-2310
Mailing Address - Fax:435-843-2304
Practice Address - Street 1:151 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2141
Practice Address - Country:US
Practice Address - Phone:435-843-2310
Practice Address - Fax:435-843-2304
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT278596-3102163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT998877663001Medicaid