Provider Demographics
NPI:1518031236
Name:ANDERSON, HEATHER COREY (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:COREY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
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 1009
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0022
Mailing Address - Country:US
Mailing Address - Phone:706-769-3331
Mailing Address - Fax:706-310-1388
Practice Address - Street 1:1351 STONEBRIDGE PKWY BLDG 105
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6037
Practice Address - Country:US
Practice Address - Phone:706-769-3331
Practice Address - Fax:706-310-1388
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN123550NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBKGZMedicare ID - Type UnspecifiedPROVIDER ID
Q67731Medicare UPIN