Basic Information
| Provider Information | |||||||||
| NPI: | 1619380623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEICHEL | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLETT | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3439 | ||||||||
| Address2: | |||||||||
| City: | NORTH MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295820439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438394447 | ||||||||
| FaxNumber: | 8433990123 | ||||||||
| Practice Location | |||||||||
| Address1: | 945 82ND PKWY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434975929 | ||||||||
| FaxNumber: | 8667789608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2014 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2139 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 2139 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1945PA | 05 | SC | MEDICAID |