Provider Demographics
NPI:1265037402
Name:MANIGAULT, HEATHER D (NURSES AIDE)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:D
Last Name:MANIGAULT
Suffix:
Gender:F
Credentials:NURSES AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 AUGUSTINE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-4102
Mailing Address - Country:US
Mailing Address - Phone:843-550-7110
Mailing Address - Fax:
Practice Address - Street 1:806 AUGUSTINE ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-4102
Practice Address - Country:US
Practice Address - Phone:843-550-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC167658376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide