Provider Demographics
NPI:1881149474
Name:MADSEN, HEATHER (CRNP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MADSEN
Suffix:
Gender:
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 S 9TH ST STE 107
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-1630
Mailing Address - Country:US
Mailing Address - Phone:855-461-3061
Mailing Address - Fax:215-709-9740
Practice Address - Street 1:7488 CALZADA DE LA FUENTE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-2717
Practice Address - Country:US
Practice Address - Phone:619-661-3823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP016589363L00000X, 363LF0000X
CA95012324363LF0000X
AZRNP256512363LP0808X
PASP025044363LP0808X
CA95195579163W00000X
PARN612893163W00000X
AZRN256512163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103223343Medicaid