Provider Demographics
NPI:1306223664
Name:HEIDEBRECHT, WANDA (RN)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:HEIDEBRECHT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-4039
Mailing Address - Country:US
Mailing Address - Phone:651-774-0202
Mailing Address - Fax:651-774-5517
Practice Address - Street 1:317 YORK AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-4039
Practice Address - Country:US
Practice Address - Phone:651-774-0202
Practice Address - Fax:651-774-5517
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR120147-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse