Provider Demographics
NPI:1477827970
Name:BURRELL, HEATHER HYACINTH (LPN)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:HYACINTH
Last Name:BURRELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 DORA AVE APT 144
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5765
Mailing Address - Country:US
Mailing Address - Phone:352-508-5368
Mailing Address - Fax:352-508-5368
Practice Address - Street 1:1821 DORA AVE APT 144
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5765
Practice Address - Country:US
Practice Address - Phone:352-508-5368
Practice Address - Fax:352-508-5368
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5158591302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization