Provider Demographics
NPI:1194201475
Name:THEOBALD, HEATHER ANN (DO)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 E MUIRWOOD DR STE 110
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7693
Mailing Address - Country:US
Mailing Address - Phone:480-763-5808
Mailing Address - Fax:480-759-0647
Practice Address - Street 1:4530 E MUIRWOOD DR STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7693
Practice Address - Country:US
Practice Address - Phone:480-763-5808
Practice Address - Fax:480-759-0647
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009525208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation