Provider Demographics
NPI:1982225538
Name:DATEMA, HEIDI LYNNE (LPN)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYNNE
Last Name:DATEMA
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 1:4499 SUMMIT FOREST DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7842
Mailing Address - Country:US
Mailing Address - Phone:847-302-6995
Mailing Address - Fax:
Practice Address - Street 1:4499 SUMMIT FOREST DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7842
Practice Address - Country:US
Practice Address - Phone:847-302-6995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703110270164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse