Provider Demographics
NPI:1093986473
Name:STAVRAKAS, HEATHER CHURCH (NP-C)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:CHURCH
Last Name:STAVRAKAS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 FRIENDS LANE
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-5175
Mailing Address - Country:US
Mailing Address - Phone:843-525-6257
Mailing Address - Fax:843-525-9418
Practice Address - Street 1:329 FRIENDS LANE
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-5175
Practice Address - Country:US
Practice Address - Phone:843-525-6257
Practice Address - Fax:843-525-9418
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC138671363L00000X
NC5003921363LA2200X
SC19200363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2593210Medicare PIN