Provider Demographics
NPI:1609445691
Name:HADDAD, HEATHER ANN (AGPC NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:HADDAD
Suffix:
Gender:F
Credentials:AGPC NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19066 FORREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-4314
Mailing Address - Country:US
Mailing Address - Phone:734-934-8468
Mailing Address - Fax:
Practice Address - Street 1:6742 PARK AVE
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2034
Practice Address - Country:US
Practice Address - Phone:313-928-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704283240363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner