Provider Demographics
NPI:1962039800
Name:MCGOVERN, HEATHER GRACE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:GRACE
Last Name:MCGOVERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40100 HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-5906
Mailing Address - Country:US
Mailing Address - Phone:863-422-4971
Mailing Address - Fax:
Practice Address - Street 1:40100 HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-5906
Practice Address - Country:US
Practice Address - Phone:863-422-4971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS19894207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program