Provider Demographics
NPI:1558822981
Name:RICHARDSON, HEATHER BERLIN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:BERLIN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 WINWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-5955
Mailing Address - Country:US
Mailing Address - Phone:757-754-4700
Mailing Address - Fax:
Practice Address - Street 1:260 GRAYSON RD STE 100
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-4345
Practice Address - Country:US
Practice Address - Phone:757-497-3670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-006779363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty