Provider Demographics
NPI:1952099350
Name:FOSSMO, HEATHER DAWN (CHW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAWN
Last Name:FOSSMO
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:DAWN
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 SW COLUMBIA ST STE 6250
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1099
Mailing Address - Country:US
Mailing Address - Phone:541-383-3005
Mailing Address - Fax:541-383-1883
Practice Address - Street 1:2084 NE PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6077
Practice Address - Country:US
Practice Address - Phone:541-383-3005
Practice Address - Fax:541-383-1883
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHCI000108207171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter