Provider Demographics
NPI:1346642311
Name:POWELL, HEATHER LEIGH PRIDGEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:LEIGH PRIDGEN
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11637 TERRACE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3707
Mailing Address - Country:US
Mailing Address - Phone:301-870-7287
Mailing Address - Fax:904-493-3395
Practice Address - Street 1:11637 TERRACE DR STE 100
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3707
Practice Address - Country:US
Practice Address - Phone:301-870-7287
Practice Address - Fax:301-870-0687
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06485363A00000X
FLPA9113940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0PK3OtherFLORIDA BLUE
FLY0PK3OtherFLORIDA BLUE