Provider Demographics
NPI:1730890989
Name:HEATWOLE, KIMBERLEY
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:HEATWOLE
Suffix:
Gender:F
Credentials:
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 7182
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-7182
Mailing Address - Country:US
Mailing Address - Phone:928-640-7454
Mailing Address - Fax:928-645-6663
Practice Address - Street 1:501 N NAVAJO DR
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0959
Practice Address - Country:US
Practice Address - Phone:928-645-0165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN126339163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant