Provider Demographics
NPI:1467105742
Name:YOUNG, HEIDI RENEE
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:RENEE
Last Name:YOUNG
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 1:1301 CRAIGMONT ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-3108
Mailing Address - Country:US
Mailing Address - Phone:702-818-0118
Mailing Address - Fax:
Practice Address - Street 1:4150 REGENTS PARK ROW
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9124
Practice Address - Country:US
Practice Address - Phone:702-818-0118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019622363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily