Provider Demographics
NPI:1689288144
Name:HEINEN, PHILLIP (APRN)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:HEINEN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1424
Mailing Address - Country:US
Mailing Address - Phone:866-414-1959
Mailing Address - Fax:855-400-0561
Practice Address - Street 1:950 WINTER ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1424
Practice Address - Country:US
Practice Address - Phone:866-414-1959
Practice Address - Fax:855-400-0561
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN211735363LF0000X
AZTEMP246634363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty