Provider Demographics
NPI:1114914967
Name:KILLAM, HEATHER (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:KILLAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:ROSHETKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:12361 W BOLA DR STE 109
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-9021
Mailing Address - Country:US
Mailing Address - Phone:623-227-1000
Mailing Address - Fax:623-227-2000
Practice Address - Street 1:12361 W BOLA DR STE 109
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9021
Practice Address - Country:US
Practice Address - Phone:623-227-1000
Practice Address - Fax:623-227-2000
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN115515363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ907157Medicaid
AZ907157Medicaid
Q28613Medicare UPIN