Provider Demographics
NPI:1013052497
Name:CHASTAIN, HEATHER COFFEEN (NP - C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:COFFEEN
Last Name:CHASTAIN
Suffix:
Gender:F
Credentials:NP - C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MICHELLE
Other - Last Name:COFFEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120-B OSIGIAN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8939
Mailing Address - Country:US
Mailing Address - Phone:478-953-5358
Mailing Address - Fax:478-953-5340
Practice Address - Street 1:306 CORDER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3606
Practice Address - Country:US
Practice Address - Phone:478-922-3074
Practice Address - Fax:478-922-3076
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA150125363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics