Provider Demographics
NPI:1457635633
Name:KALLESTAD, HEIDI RUTH (ANP-C)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:RUTH
Last Name:KALLESTAD
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24306 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-9656
Mailing Address - Country:US
Mailing Address - Phone:206-999-8229
Mailing Address - Fax:
Practice Address - Street 1:3050 REGENT BLVD STE 400
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-5808
Practice Address - Country:US
Practice Address - Phone:214-689-8067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID23483-A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health