Provider Demographics
NPI:1912406406
Name:MOORE, HEATHER BRECKENRIDGE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:BRECKENRIDGE
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANNETTE
Other - Last Name:BRECKENRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:123 GUNSMOKE LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:AR
Mailing Address - Zip Code:72007-8092
Mailing Address - Country:US
Mailing Address - Phone:870-476-6921
Mailing Address - Fax:
Practice Address - Street 1:2 SAINT VINCENT CIR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-552-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005506363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care