Provider Demographics
NPI:1467443630
Name:MACKEY, HEATHER THOMPSON (ANP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:THOMPSON
Last Name:MACKEY
Suffix:
Gender:F
Credentials:ANP
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 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-1000
Mailing Address - Fax:336-718-1052
Practice Address - Street 1:250 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-718-1000
Practice Address - Fax:336-718-1052
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900298363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003716Medicaid
NC2805366CMedicare PIN
NC7003716Medicaid
NC2333292Medicare ID - Type Unspecified
NC2805366DMedicare PIN