Provider Demographics
NPI:1093225070
Name:EDMONDSON, HEATHER LARUE (FNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LARUE
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 813
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MS
Mailing Address - Zip Code:38827-0813
Mailing Address - Country:US
Mailing Address - Phone:662-454-3401
Mailing Address - Fax:
Practice Address - Street 1:102 3RD ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MS
Practice Address - Zip Code:38827
Practice Address - Country:US
Practice Address - Phone:662-454-3401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-163717363LF0000X
MS902349363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty