Provider Demographics
NPI:1891042750
Name:HAASL VANORNUM, HEIDI L
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:L
Last Name:HAASL VANORNUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:L
Other - Last Name:HAASL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 MADGE AVE LOT 3
Mailing Address - Street 2:
Mailing Address - City:EDGAR
Mailing Address - State:WI
Mailing Address - Zip Code:54426-9398
Mailing Address - Country:US
Mailing Address - Phone:715-570-9757
Mailing Address - Fax:
Practice Address - Street 1:700 MADGE AVE LOT 3
Practice Address - Street 2:
Practice Address - City:EDGAR
Practice Address - State:WI
Practice Address - Zip Code:54426-9398
Practice Address - Country:US
Practice Address - Phone:715-570-9757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI307303164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse