Provider Demographics
NPI:1518007699
Name:FISHER, HEATHER REBECCA
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:REBECCA
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:REBECCA
Other - Last Name:MULLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2940 E PARK AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-3446
Mailing Address - Country:US
Mailing Address - Phone:850-274-1052
Mailing Address - Fax:
Practice Address - Street 1:2940 E PARK AVE STE 1
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3446
Practice Address - Country:US
Practice Address - Phone:850-274-1052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3568133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered