Provider Demographics
NPI:1861435521
Name:LANGE, HEATHER S (APRN)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:S
Last Name:LANGE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12201 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:502-568-7366
Mailing Address - Fax:502-568-7114
Practice Address - Street 1:2100 MILLVALE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1604
Practice Address - Country:US
Practice Address - Phone:502-451-0990
Practice Address - Fax:502-459-1018
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28160594A363L00000X
KY3004811363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200531340Medicaid
KY143319OtherSIHO - WS
KY7100224710Medicaid
KY000000798249OtherANTHEM - WS
KY50045366OtherPASSPORT - WS
Q63517Medicare UPIN
KYK067600Medicare PIN
KY000000798249OtherANTHEM - WS
IN122780EMedicare PIN