Provider Demographics
NPI:1043046147
Name:DEITER, HEATHER MARIE RENEE (RN)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE RENEE
Last Name:DEITER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 PARK VIEW RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53531-9548
Mailing Address - Country:US
Mailing Address - Phone:920-728-4441
Mailing Address - Fax:
Practice Address - Street 1:1515 HOMMEN RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:WI
Practice Address - Zip Code:53531-9678
Practice Address - Country:US
Practice Address - Phone:608-444-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI228840163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty