Provider Demographics
NPI:1851540728
Name:PONALL, HEATHER MARIE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MARIE
Last Name:PONALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5139 KARLSBURG PL
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-3619
Mailing Address - Country:US
Mailing Address - Phone:727-644-1388
Mailing Address - Fax:
Practice Address - Street 1:3910 NORTHDALE BLVD STE 206
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624
Practice Address - Country:US
Practice Address - Phone:813-264-7922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9200004363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily