Provider Demographics
NPI:1578878112
Name:HEINICKE, MARY ANN (RN CNNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:HEINICKE
Suffix:
Gender:F
Credentials:RN CNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR097601-1363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal