Provider Demographics
NPI:1689380149
Name:HEIDERSCHEIDT, NIKKI
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:HEIDERSCHEIDT
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 1:538 3RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:SLEEPY EYE
Mailing Address - State:MN
Mailing Address - Zip Code:56085-1037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 1ST AVE S
Practice Address - Street 2:
Practice Address - City:SLEEPY EYE
Practice Address - State:MN
Practice Address - Zip Code:56085-1364
Practice Address - Country:US
Practice Address - Phone:507-794-3631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist