Provider Demographics
NPI:1235727686
Name:RICHARDSON, HEATHER L (FNP-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 ROCKY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-9794
Mailing Address - Country:US
Mailing Address - Phone:704-746-6994
Mailing Address - Fax:
Practice Address - Street 1:557 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4100
Practice Address - Country:US
Practice Address - Phone:704-873-5661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC263284163W00000X
NCF01210773363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse