Provider Demographics
NPI:1770164428
Name:DOUGLAS, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:DOUGLAS
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 1:4303 LUDGATE ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2460
Mailing Address - Country:US
Mailing Address - Phone:910-338-4593
Mailing Address - Fax:910-202-4973
Practice Address - Street 1:4303 LUDGATE ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2460
Practice Address - Country:US
Practice Address - Phone:910-338-4593
Practice Address - Fax:910-202-4973
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5016748363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily