Provider Demographics
NPI:1942431358
Name:HEIDE, MICHLYNN RAE (DC)
Entity Type:Individual
Prefix:
First Name:MICHLYNN
Middle Name:RAE
Last Name:HEIDE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 8TH AVE N
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7611
Mailing Address - Country:US
Mailing Address - Phone:952-933-5085
Mailing Address - Fax:952-931-2159
Practice Address - Street 1:15 8TH AVE N
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-7611
Practice Address - Country:US
Practice Address - Phone:952-933-5085
Practice Address - Fax:952-931-2159
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5257111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
37M47FIOtherBLUE CROSS GROUP ID NUMBER
350004449OtherMEDICARE ID NUMBER
1639349269OtherMEDICARE GROUP ID NUMBER