Provider Demographics
NPI:1235688268
Name:HECKENLAIBLE, NICOLE ANDREA (DENTAL HYGIENE)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANDREA
Last Name:HECKENLAIBLE
Suffix:
Gender:F
Credentials:DENTAL HYGIENE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:LA PUSH
Mailing Address - State:WA
Mailing Address - Zip Code:98350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 QUILEUTE HEIGHTS
Practice Address - Street 2:QUILEUTE HEALTH CENTER
Practice Address - City:LA PUSH
Practice Address - State:WA
Practice Address - Zip Code:98350
Practice Address - Country:US
Practice Address - Phone:360-374-6984
Practice Address - Fax:360-374-9049
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00007007124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist