Basic Information
| Provider Information | |||||||||
| NPI: | 1104439587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRAFT | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CG 61090134 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2429 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986328486 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 FIR ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605753316 | ||||||||
| FaxNumber: | 3604237813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2020 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | 61090134 | WA | Y |
No ID Information.