Provider Demographics
NPI:1154863827
Name:CROSSLEY, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:CROSSLEY
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 1:4624 S HOLLADAY BLVD.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7168
Mailing Address - Country:US
Mailing Address - Phone:801-266-3113
Mailing Address - Fax:801-266-5633
Practice Address - Street 1:745 S PROGRESS AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5610
Practice Address - Country:US
Practice Address - Phone:208-813-1958
Practice Address - Fax:208-600-6905
Is Sole Proprietor?:No
Enumeration Date:2016-11-13
Last Update Date:2023-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-28059390200000X
ID66212363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program