Provider Demographics
NPI:1629220462
Name:OLMOS, HEATHER LARAE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LARAE
Last Name:OLMOS
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 1:2733 QUAIL RUN DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-3448
Mailing Address - Country:US
Mailing Address - Phone:520-459-2371
Mailing Address - Fax:
Practice Address - Street 1:2733 QUAIL RUN DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-3448
Practice Address - Country:US
Practice Address - Phone:520-459-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11412385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ00000000Medicaid