Provider Demographics
NPI:1225297484
Name:HEISEL-WOLTER, JULIE R (CRNA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:R
Last Name:HEISEL-WOLTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:R
Other - Last Name:HEISEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1505 EASTLAND DR
Mailing Address - Street 2:SUITE LL 1400
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3534
Mailing Address - Country:US
Mailing Address - Phone:309-663-4700
Mailing Address - Fax:309-665-0575
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:SUITE LL 1400
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3534
Practice Address - Country:US
Practice Address - Phone:309-663-4700
Practice Address - Fax:309-665-0575
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007131367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered