Provider Demographics
NPI:1043518392
Name:EDWARDS, HEATHER C (LAC, MAOM)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:C
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LAC, MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4104 PRESTON RUN
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-1954
Mailing Address - Country:US
Mailing Address - Phone:818-625-7096
Mailing Address - Fax:
Practice Address - Street 1:110 GLANCY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-2326
Practice Address - Country:US
Practice Address - Phone:818-625-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN179171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist