Provider Demographics
NPI:1891964870
Name:MUNGER, HEATHER PATRICIA (LPN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:PATRICIA
Last Name:MUNGER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5773 LIMESTONE LANE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:14425
Mailing Address - Country:US
Mailing Address - Phone:585-354-5619
Mailing Address - Fax:
Practice Address - Street 1:5773 LIMESTONE LANE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425
Practice Address - Country:US
Practice Address - Phone:585-354-5619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274207164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02640408Medicaid