Provider Demographics
NPI:1336637453
Name:TULLY, HEATHER (MSN FNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
Credentials:MSN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 SLEEPY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-2782
Mailing Address - Country:US
Mailing Address - Phone:440-308-5385
Mailing Address - Fax:
Practice Address - Street 1:56 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKEMAN
Practice Address - State:OH
Practice Address - Zip Code:44889-9492
Practice Address - Country:US
Practice Address - Phone:216-267-5445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.347407163W00000X
OHAPRN.CNP.023337363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse