Provider Demographics
NPI:1689689085
Name:HEIDENREICH, TANYA (CFNP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:HEIDENREICH
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2199 W IRONWOOD CENTER DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2639
Mailing Address - Country:US
Mailing Address - Phone:208-625-4888
Mailing Address - Fax:
Practice Address - Street 1:2199 W IRONWOOD CENTER DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2639
Practice Address - Country:US
Practice Address - Phone:208-625-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP358A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805146700Medicaid
ID000010015819OtherREGENCE BLUE SHIELD
IDNP659OtherBLUE CROSS
IDNP659OtherBLUE CROSS
555251Medicare UPIN