Provider Demographics
NPI:1689046146
Name:VANDERSLOOT, HEATHER LYNN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:VANDERSLOOT
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 1:2861 STATE HIGHWAY 7
Mailing Address - Street 2:
Mailing Address - City:OTEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13825-2139
Mailing Address - Country:US
Mailing Address - Phone:607-353-2183
Mailing Address - Fax:
Practice Address - Street 1:2861 STATE HIGHWAY 7
Practice Address - Street 2:
Practice Address - City:OTEGO
Practice Address - State:NY
Practice Address - Zip Code:13825-2139
Practice Address - Country:US
Practice Address - Phone:607-353-2183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY474038769305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service