Provider Demographics
NPI:1801850524
Name:SORUM, HEATHER J (NP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:J
Last Name:SORUM
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 1:721 AMERICAN AVE STE 205
Mailing Address - Street 2:PROHEALTH CARE DIABETES CENTER
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5071
Mailing Address - Country:US
Mailing Address - Phone:262-928-4695
Mailing Address - Fax:
Practice Address - Street 1:721 AMERICAN AVE STE 205
Practice Address - Street 2:PROHEALTH CARE DIABETES CENTER
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5071
Practice Address - Country:US
Practice Address - Phone:262-928-4695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2113363L00000X, 363LA2200X
WI136222363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43979600Medicaid
68375Medicare PIN
WI032C15875Medicare ID - Type Unspecified
WI43979600Medicaid