Provider Demographics
NPI:1366427858
Name:WADDELL, HEATHER SIMMONS (CRNA)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:SIMMONS
Last Name:WADDELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 NORMAN DR
Mailing Address - Street 2:
Mailing Address - City:KING
Mailing Address - State:NC
Mailing Address - Zip Code:27021-8387
Mailing Address - Country:US
Mailing Address - Phone:336-985-0461
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-713-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC117142367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051644Medicaid
NC8051644Medicaid