Provider Demographics
NPI:1689830838
Name:MOULZOLF, HEATHER L (ARNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:MOULZOLF
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8267 COLLEGE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919
Mailing Address - Country:US
Mailing Address - Phone:239-936-8151
Mailing Address - Fax:239-936-1139
Practice Address - Street 1:8267 COLLEGE PARKWAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919
Practice Address - Country:US
Practice Address - Phone:239-936-8151
Practice Address - Fax:239-936-1139
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP92764231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP74951Medicare UPIN