Provider Demographics
NPI:1447006705
Name:WYDRA, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WYDRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5651 MORELAND ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-1115
Mailing Address - Country:US
Mailing Address - Phone:202-669-6163
Mailing Address - Fax:
Practice Address - Street 1:2121 EISENHOWER AVE STE 103
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-5305
Practice Address - Country:US
Practice Address - Phone:540-845-6940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-27
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program