Provider Demographics
NPI:1528042116
Name:MACLEAN, HEATHER RENEE (RN, NMNP - PP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENEE
Last Name:MACLEAN
Suffix:
Gender:F
Credentials:RN, NMNP - PP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4585
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4585
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR095000395N5363L00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCD8723OtherRR MEDICARE GROUP NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR090501Medicaid
OR420001224OtherRR MEDICARE PTAN NUMBER
OR1407812365OtherNBMC NPI NUMBER-GROUP
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR090501Medicaid
OR930635514OtherGROUP TAX ID NUMBER
OR1407812365OtherNBMC NPI NUMBER-GROUP