Provider Demographics
NPI:1841804234
Name:HEATWOLE, MARIEKE NMN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MARIEKE
Middle Name:NMN
Last Name:HEATWOLE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E DIMOND BLVD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1909
Mailing Address - Country:US
Mailing Address - Phone:907-677-5910
Mailing Address - Fax:907-600-7711
Practice Address - Street 1:4101 ARCTIC BLVD STE 104
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-5702
Practice Address - Country:US
Practice Address - Phone:907-677-5910
Practice Address - Fax:907-600-7711
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK118269163W00000X, 363LP0808X
AK165235363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse