Provider Demographics
NPI:1184375800
Name:ANDERSON, HEATHER BROOKE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:BROOKE
Last Name:ANDERSON
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 1:725 US HIGHWAY 19 S
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-6396
Mailing Address - Country:US
Mailing Address - Phone:229-336-5208
Mailing Address - Fax:
Practice Address - Street 1:725 US HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-6396
Practice Address - Country:US
Practice Address - Phone:229-336-5208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN242510363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily