Provider Demographics
NPI:1649442849
Name:NUTTALL, HEIDI KATHLEEN HYNES (PA-C)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:KATHLEEN HYNES
Last Name:NUTTALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 KENNEDY DR
Mailing Address - Street 2:STE 100
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915
Mailing Address - Country:US
Mailing Address - Phone:815-928-8050
Mailing Address - Fax:
Practice Address - Street 1:400 KENNEDY DR
Practice Address - Street 2:STE 100
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915
Practice Address - Country:US
Practice Address - Phone:815-928-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003195363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB131704Medicare PIN
TXTXB132050Medicare PIN