Provider Demographics
NPI:1215362785
Name:WILCKE, HEATHER ANN (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:WILCKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:SUITE 303
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-2800
Practice Address - Country:US
Practice Address - Phone:208-367-2800
Practice Address - Fax:208-367-7111
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1342A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner