Provider Demographics
NPI:1144399957
Name:HEFFERNAN, THERESA A (CRNA)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:A
Last Name:HEFFERNAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 PENNY AVE
Mailing Address - Street 2:
Mailing Address - City:EAST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-1454
Mailing Address - Country:US
Mailing Address - Phone:847-836-7015
Mailing Address - Fax:
Practice Address - Street 1:160 NW 170TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-5521
Practice Address - Country:US
Practice Address - Phone:305-654-3041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-169856367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041-169856OtherIL STATE LICENSE
IL031617OtherCRNA RE-CERT CARD