Provider Demographics
NPI:1700292232
Name:SHATTUCK, HEATHER ANN (ACNP-BC)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:ANN
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 836 BOX 105
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09636-0002
Mailing Address - Country:US
Mailing Address - Phone:348-719-7007
Mailing Address - Fax:
Practice Address - Street 1:PSC 836 BOX 2670
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09636-9998
Practice Address - Country:US
Practice Address - Phone:348-719-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-04
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171790363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care