Provider Demographics
NPI:1184989881
Name:HEAPHY, KRISTEN LEE (FNP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEE
Last Name:HEAPHY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LEE
Other - Last Name:VICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5008 BRITTONFIELD PKWY
Mailing Address - Street 2:SUITE 700
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9248
Mailing Address - Country:US
Mailing Address - Phone:315-472-7504
Mailing Address - Fax:315-634-4677
Practice Address - Street 1:5008 BRITTONFIELD PKWY
Practice Address - Street 2:SUITE 700
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:315-472-7504
Practice Address - Fax:315-634-4677
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF337409-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03996090Medicaid
NY03996090Medicaid