Provider Demographics
NPI:1205192689
Name:MYRICK, HEATHER WARNER (APRN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:WARNER
Last Name:MYRICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PEBBLE DIVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489
Mailing Address - Country:US
Mailing Address - Phone:860-620-0335
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-6220
Practice Address - Country:US
Practice Address - Phone:860-679-4477
Practice Address - Fax:860-679-4474
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005176363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1205192689Medicaid