Provider Demographics
NPI:1891428157
Name:DEDRICK, HEATHER (RN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:DEDRICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:80 STATE HIGHWAY 310 STE 1
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1436
Mailing Address - Country:US
Mailing Address - Phone:315-386-2189
Mailing Address - Fax:
Practice Address - Street 1:80 STATE HIGHWAY 310 STE 1
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1436
Practice Address - Country:US
Practice Address - Phone:315-386-2189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY718792163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)