Provider Demographics
NPI:1407812167
Name:HEETER, LONNIE L (CRNP)
Entity Type:Individual
Prefix:MR
First Name:LONNIE
Middle Name:L
Last Name:HEETER
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W CRESCENT PARK
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2111
Mailing Address - Country:US
Mailing Address - Phone:814-723-3300
Mailing Address - Fax:814-723-8952
Practice Address - Street 1:103 W SAINT CLAIR ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2197
Practice Address - Country:US
Practice Address - Phone:814-723-1212
Practice Address - Fax:814-723-3466
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP005151B363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA013892D6JMedicare ID - Type Unspecified