Provider Demographics
NPI:1679598791
Name:PUCKETT, HEATHER CAUDILL (ANP-C)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:CAUDILL
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEDICAL PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-0906
Mailing Address - Country:US
Mailing Address - Phone:704-786-1108
Mailing Address - Fax:704-782-1826
Practice Address - Street 1:200 MEDICAL PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-0906
Practice Address - Country:US
Practice Address - Phone:704-786-1108
Practice Address - Fax:704-782-1826
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900455363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC900455OtherNC MEDICAL BOARD LICENSE
NC900455OtherNC MEDICAL BOARD LICENSE