Provider Demographics
NPI:1316413768
Name:HEATHERTON, AMIE
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:
Last Name:HEATHERTON
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 1:98 POPLAR ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1799
Mailing Address - Country:US
Mailing Address - Phone:208-782-2450
Mailing Address - Fax:208-782-9953
Practice Address - Street 1:98 POPLAR ST FL 2
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1799
Practice Address - Country:US
Practice Address - Phone:208-782-2450
Practice Address - Fax:208-782-9953
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator