Basic Information
| Provider Information | |||||||||
| NPI: | 1528042116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACLEAN | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | RN, NMNP - PP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664585 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 095000395N5 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367A00000X | 095000395N5 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | CD8723 | 01 | OR | RR MEDICARE GROUP NUMBER | OTHER | R0000WFBTV | 01 | OR | MEDICARE GROUP PIN NUMBER | OTHER | 090501 | 05 | OR | MEDICAID | 420001224 | 01 | OR | RR MEDICARE PTAN NUMBER | OTHER | 1407812365 | 01 | OR | NBMC NPI NUMBER-GROUP | OTHER |