Provider Demographics
NPI:1104557735
Name:SHOULTZ, HEATHER DOW (NP)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:DOW
Last Name:SHOULTZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-9428
Mailing Address - Country:US
Mailing Address - Phone:504-232-5404
Mailing Address - Fax:
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-345-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA226156363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA15653286OtherCAQH