Provider Demographics
NPI:1982688735
Name:PICKETT, HEATHER RENE (DO)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:RENE
Last Name:PICKETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 S 1300 W
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-3761
Mailing Address - Country:US
Mailing Address - Phone:385-440-1400
Mailing Address - Fax:801-845-9965
Practice Address - Street 1:360 S 1300 W
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3761
Practice Address - Country:US
Practice Address - Phone:385-440-1400
Practice Address - Fax:801-845-9965
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111670207Q00000X
UT10903589-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN