Provider Demographics
NPI:1871007526
Name:KOWALISHEN, HEATHER MICHELLE (CRNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:KOWALISHEN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MICHELLE
Other - Last Name:PREVOZNIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:106 SHAWNEE SQUARE SUITE 101
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE ON DELAWARE
Mailing Address - State:PA
Mailing Address - Zip Code:18356
Mailing Address - Country:US
Mailing Address - Phone:570-421-3900
Mailing Address - Fax:
Practice Address - Street 1:179 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301
Practice Address - Country:US
Practice Address - Phone:570-421-3900
Practice Address - Fax:570-424-1549
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA637151PZPOtherMEDICARE