Provider Demographics
NPI:1346608957
Name:WAHL, HEATHER K (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:K
Last Name:WAHL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:K
Other - Last Name:CUYKENDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 TOWN CENTER DRIVE
Mailing Address - Street 2:#203
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:248-585-8250
Mailing Address - Fax:248-585-8270
Practice Address - Street 1:3601 W. 13 MILE RD.
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-7784
Practice Address - Fax:248-898-8181
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272890367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered