Provider Demographics
NPI:1609121508
Name:DEJARNETT, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:DEJARNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:DEJARNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM
Mailing Address - Street 1:11133 SWEETWATER PATH
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-5293
Mailing Address - Country:US
Mailing Address - Phone:651-895-0055
Mailing Address - Fax:
Practice Address - Street 1:5640 MEMORIAL AVE N
Practice Address - Street 2:SUITE B
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-2166
Practice Address - Country:US
Practice Address - Phone:651-430-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12608367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife