Provider Demographics
NPI:1720312523
Name:BAGLEY, HEATHER ANNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ANNE
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7579
Mailing Address - Country:US
Mailing Address - Phone:208-523-3060
Mailing Address - Fax:
Practice Address - Street 1:3430 WASHINGTON PKWY
Practice Address - Street 2:THE PEDIATRIC CENTER
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7579
Practice Address - Country:US
Practice Address - Phone:208-523-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID20366A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics