Provider Demographics
NPI:1609087972
Name:ANDERSON, STEPHANIE HEATON (PNP, DNP, RNCS)
Entity Type:Individual
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First Name:STEPHANIE
Middle Name:HEATON
Last Name:ANDERSON
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Gender:F
Credentials:PNP, DNP, RNCS
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Mailing Address - Street 1:391 EAST MAIN STREET
Mailing Address - Street 2:1 HISTORIC HAWKINS BUILDING
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2712
Mailing Address - Country:US
Mailing Address - Phone:770-720-6963
Mailing Address - Fax:770-720-6965
Practice Address - Street 1:391 EAST MAIN STREET
Practice Address - Street 2:1 HISTORIC HAWKINS BUILDING
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2712
Practice Address - Country:US
Practice Address - Phone:770-720-6963
Practice Address - Fax:770-720-6965
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2011-10-28
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Provider Licenses
StateLicense IDTaxonomies
GARN173488363LP0200X, 363LW0102X, 363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA495715792AOtherMEDICAID PROVIDER ID, STEPHANIE H. ANDERSON, PNP, APRN, NPI# 1609087972
GA629697125AOtherMEDICAID PAYOR ID, NORTHSIDE CHILDREN'S PEDIATRICS CTR, NPI# 1396945515
GAGA 54532OtherAUTHORIZED CONTACT REPRESENTATIVE: MICHAEL G. ANDERSON, MD (ATTENDING PHYSICIAN)