Basic Information
| Provider Information | |||||||||
| NPI: | 1215975313 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | HERITAGE | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NMNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE | ||||||||
| Address2: | DEPT 358 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986839324 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 353 DEADMOND FERRY RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974779406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412227750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 03/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | 089006318N5 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 080205 | 05 | OR | MEDICAID |