Provider Demographics
NPI:1578165080
Name:MARKS, HEATHER ELLEN
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:ELLEN
Last Name:MARKS
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:S2845 WHITE EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-9064
Mailing Address - Country:US
Mailing Address - Phone:608-355-5177
Mailing Address - Fax:608-356-1233
Practice Address - Street 1:S2845 WHITE EAGLE RD
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-9064
Practice Address - Country:US
Practice Address - Phone:608-355-5177
Practice Address - Fax:608-356-1233
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0902238OtherCPHT