Provider Demographics
NPI:1497731624
Name:SANDY, HEATHER A (MA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:SANDY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:A
Other - Last Name:SOUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2215 E 52ND ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2786
Mailing Address - Country:US
Mailing Address - Phone:563-355-7712
Mailing Address - Fax:
Practice Address - Street 1:2215 E 52ND ST
Practice Address - Street 2:SUITE 2
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2786
Practice Address - Country:US
Practice Address - Phone:563-355-7712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-001232231H00000X
IA934237700000X
IA611231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1457365520Medicaid
ILK39241Medicare UPIN
IAI20167Medicare UPIN