Provider Demographics
NPI:1255795415
Name:HARGETT, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:HARGETT
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 1:520 PEGRAM DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6347
Mailing Address - Country:US
Mailing Address - Phone:662-842-5363
Mailing Address - Fax:662-842-5366
Practice Address - Street 1:520 PEGRAM DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6347
Practice Address - Country:US
Practice Address - Phone:662-842-5363
Practice Address - Fax:662-842-5366
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS640936379174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00441006Medicaid
417776002Medicare UPIN
MS1831162932Medicare PIN