Provider Demographics
NPI:1962473926
Name:CHAMPAGNE, HEATHER LYNN (PA)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:LYNN
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-2016
Mailing Address - Country:US
Mailing Address - Phone:860-224-5691
Mailing Address - Fax:860-224-5795
Practice Address - Street 1:100 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-2016
Practice Address - Country:US
Practice Address - Phone:860-224-5691
Practice Address - Fax:860-224-5795
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001750363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001750OtherLICENSE