Provider Demographics
NPI:1902062730
Name:JOLIVETTE, HEATHER ANN (CPNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:JOLIVETTE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:A
Other - Last Name:GATHERCOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RI 5960
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-3889
Practice Address - Fax:317-944-3882
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28147487363LP0200X
IN71002197363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201136110Medicaid
IN145590111Medicare PIN