Provider Demographics
NPI:1255717807
Name:KILLPACK, HEATHER NICHOLE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICHOLE
Last Name:KILLPACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KOALY
Other - Middle Name:NICHOLE
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13923 S HAYSTACK PEAK CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6453
Mailing Address - Country:US
Mailing Address - Phone:801-506-6695
Mailing Address - Fax:
Practice Address - Street 1:13923 S HAYSTACK PEAK CIR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-6453
Practice Address - Country:US
Practice Address - Phone:801-506-6695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist