Basic Information
| Provider Information | |||||||||
| NPI: | 1194211748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BADGER | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAHAM | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1130 RACE RD | ||||||||
| Address2: | |||||||||
| City: | COUPEVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982399528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609290021 | ||||||||
| FaxNumber: | 2082622390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 RACE RD | ||||||||
| Address2: | |||||||||
| City: | COUPEVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982399528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609290021 | ||||||||
| FaxNumber: | 2082622390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2018 | ||||||||
| LastUpdateDate: | 10/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 69887 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | AP60867565 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | AP60867565 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1194211748 | 05 | ID | MEDICAID |