Provider Demographics
NPI:1265019277
Name:HEATHCOCK, MICHELLE DENISE (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DENISE
Last Name:HEATHCOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2059 W DANIEL RD
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-8891
Mailing Address - Country:US
Mailing Address - Phone:480-340-6277
Mailing Address - Fax:
Practice Address - Street 1:920 E WILLIAMS FIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-4880
Practice Address - Country:US
Practice Address - Phone:480-499-0201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ255923363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD03876543OtherDRIVERS LICENSE