Provider Demographics
NPI:1306210141
Name:STOCKWELL, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:STOCKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 WESTERN AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-6021
Mailing Address - Country:US
Mailing Address - Phone:509-379-4113
Mailing Address - Fax:
Practice Address - Street 1:1881 WESTERN AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-6021
Practice Address - Country:US
Practice Address - Phone:509-379-4113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288279-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse