Provider Demographics
NPI:1649508854
Name:NYSTROM, HEATHER EVELYN (NNP-BC)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:EVELYN
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:EVELYN
Other - Last Name:ABRAAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:313-916-0467
Mailing Address - Fax:313-916-9485
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-0467
Practice Address - Fax:313-916-9485
Is Sole Proprietor?:No
Enumeration Date:2009-11-28
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704203209363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal