Provider Demographics
NPI:1619616323
Name:PETTS, HEIDI (RN)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:PETTS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:VANDESLUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 W SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-2342
Mailing Address - Country:US
Mailing Address - Phone:920-926-0101
Mailing Address - Fax:
Practice Address - Street 1:8444 N 90TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4437
Practice Address - Country:US
Practice Address - Phone:920-926-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI235370163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)