Provider Demographics
NPI:1255814935
Name:SMITH, HEATHER E
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:BEHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:ATTN INSURANCE CREDENTIALING
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-0372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4644
Practice Address - Country:US
Practice Address - Phone:217-255-4150
Practice Address - Fax:217-258-2579
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018045363L00000X
IL209-018045363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner