Provider Demographics
NPI:1518164607
Name:WEDGWORTH, HEATHER R (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:R
Last Name:WEDGWORTH
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3361
Mailing Address - Country:US
Mailing Address - Phone:252-338-2114
Mailing Address - Fax:252-338-2115
Practice Address - Street 1:110 S US HWY 64/264
Practice Address - Street 2:
Practice Address - City:MANTEO
Practice Address - State:NC
Practice Address - Zip Code:27954
Practice Address - Country:US
Practice Address - Phone:252-261-1556
Practice Address - Fax:252-261-6161
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212329Medicaid
NC068WUOtherBCBS
NC250235Medicare PIN
NC7212329Medicaid
NC271572BMedicare PIN