Basic Information
| Provider Information | |||||||||
| NPI: | 1881310068 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREEBORN | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KIDD | ||||||||
| OtherFirstName: | HEIDI | ||||||||
| OtherMiddleName: | JO | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10335 BIRCH LN | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995778376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077271642 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1363 W SPRUCE AVE | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996545327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073762411 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2022 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | NURR36448 | AK | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 199969 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.