Provider Demographics
NPI:1679981294
Name:GRAYSON, HEATHER (APRN, PNP-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:APRN, PNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PAVILION RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-9470
Mailing Address - Country:US
Mailing Address - Phone:318-323-1100
Mailing Address - Fax:318-323-1161
Practice Address - Street 1:300 PAVILION RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71292-9470
Practice Address - Country:US
Practice Address - Phone:318-323-1100
Practice Address - Fax:318-323-1161
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07983363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09023298Medicaid
LA2375938Medicaid
LA2375938Medicaid