Basic Information
| Provider Information | |||||||||
| NPI: | 1841954641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARRACLOUGH | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 825 BENNETT AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417795228 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 825 BENNETT AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417795228 | ||||||||
| FaxNumber: | 5417086372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2021 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 202112847NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 202112847NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 208VP0000X | 202112847NP-PP | OR | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1841954641 | 05 | OR | MEDICAID |