Provider Demographics
NPI:1912906470
Name:CARLSON, HEIDI JO (FNP)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:JO
Last Name:CARLSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6579
Mailing Address - Street 2:446 OAK ST / 6579
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0285
Mailing Address - Country:US
Mailing Address - Phone:541-412-8898
Mailing Address - Fax:541-412-7420
Practice Address - Street 1:446 OAK ST / 6579
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-0285
Practice Address - Country:US
Practice Address - Phone:541-412-8898
Practice Address - Fax:541-412-7420
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200150156363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100122Medicaid
OR100122Medicaid
OR115363Medicare ID - Type Unspecified