Provider Demographics
NPI:1518254143
Name:MOOREHEAD, HEATHER KAY (ARNP)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:KAY
Last Name:MOOREHEAD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:KAY
Other - Last Name:POUCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP-BC
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9700
Mailing Address - Fax:239-343-9699
Practice Address - Street 1:8960 COLONIAL CENTER DR STE 302
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-9700
Practice Address - Fax:239-343-9699
Is Sole Proprietor?:No
Enumeration Date:2011-07-04
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704253434163WC0200X, 363L00000X, 363LA2100X
FLARNP9426987363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016896100Medicaid