Provider Demographics
NPI:1548395684
Name:HEATH, JOAN ALICE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:ALICE
Last Name:HEATH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N168W21700 MAIN ST LOT 122
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037
Mailing Address - Country:US
Mailing Address - Phone:262-671-3126
Mailing Address - Fax:
Practice Address - Street 1:N168W21700 MAIN ST LOT 122
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WI
Practice Address - Zip Code:53037
Practice Address - Country:US
Practice Address - Phone:262-671-3126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83417030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39951200Medicaid