Provider Demographics
NPI:1356850119
Name:KOPESKY, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:KOPESKY
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 1:990 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-2936
Mailing Address - Country:US
Mailing Address - Phone:920-882-6200
Mailing Address - Fax:920-239-6894
Practice Address - Street 1:990 PLANK RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-2936
Practice Address - Country:US
Practice Address - Phone:920-882-6200
Practice Address - Fax:920-239-6894
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI252-49176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty