Basic Information
| Provider Information | |||||||||
| NPI: | 1124140116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIESTAND | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | JO | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 12229 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926852229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884322088 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 W 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992054805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094743131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 12/16/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | IT40000963 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 9652546 | 05 | WA | MEDICAID |