Provider Demographics
NPI:1750040432
Name:HEIDEMANN, HOLLY MARIE (TOXICOLOGYFACILITATO)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:MARIE
Last Name:HEIDEMANN
Suffix:
Gender:F
Credentials:TOXICOLOGYFACILITATO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-233-0940
Mailing Address - Fax:208-233-0942
Practice Address - Street 1:350 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-233-0940
Practice Address - Fax:208-233-0942
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory