Provider Demographics
NPI:1821344763
Name:HEATHERLY, REBECCA (LPN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HEATHERLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SCRANTON CONNECTOR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-0540
Mailing Address - Country:US
Mailing Address - Phone:912-280-1462
Mailing Address - Fax:912-262-3036
Practice Address - Street 1:1501 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:GA
Practice Address - Zip Code:31569-5504
Practice Address - Country:US
Practice Address - Phone:912-576-3040
Practice Address - Fax:912-576-3833
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA80366164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse