Provider Demographics
NPI:1689604845
Name:WARREN, HEATHER E (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:E
Last Name:WARREN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:E
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:705 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3818
Mailing Address - Country:US
Mailing Address - Phone:770-836-9561
Mailing Address - Fax:
Practice Address - Street 1:204 ALLEN MEMORIAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2047
Practice Address - Country:US
Practice Address - Phone:770-537-6500
Practice Address - Fax:770-824-2600
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q57841Medicare UPIN