Provider Demographics
NPI:1578368882
Name:PACK, HEATHER NICOLE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:PACK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11760 S STATE ROUTE 20
Mailing Address - Street 2:
Mailing Address - City:PIPESTEM
Mailing Address - State:WV
Mailing Address - Zip Code:25979-7976
Mailing Address - Country:US
Mailing Address - Phone:681-305-9932
Mailing Address - Fax:
Practice Address - Street 1:11760 S STATE ROUTE 20
Practice Address - Street 2:
Practice Address - City:PIPESTEM
Practice Address - State:WV
Practice Address - Zip Code:25979-7976
Practice Address - Country:US
Practice Address - Phone:681-305-9932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant