Provider Demographics
NPI:1871078808
Name:CHAMBERLAIN, HEATHER ELIZABETH (DNP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELIZABETH
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ELIZABETH
Other - Last Name:LYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:21616 76TH AVE W STE 113
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7512
Practice Address - Country:US
Practice Address - Phone:425-640-4636
Practice Address - Fax:425-673-3953
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60903132363L00000X
WARN60475412163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1871078808Medicaid