Provider Demographics
NPI:1023301595
Name:TACK, HEATHER (NP)
Entity type:Individual
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First Name:HEATHER
Middle Name:
Last Name:TACK
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:901 MCCLINTOCK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0844
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-734-4715
Practice Address - Street 1:15474 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48170-0844
Practice Address - Country:US
Practice Address - Phone:248-615-0889
Practice Address - Fax:734-404-5317
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2013-04-19
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Provider Licenses
StateLicense IDTaxonomies
MI4704222690363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5695012Medicare PIN