Provider Demographics
NPI:1386815694
Name:SWANN, HEATHER NICOLE (NP)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:NICOLE
Last Name:SWANN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:SWANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:4333 15TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2525
Mailing Address - Country:US
Mailing Address - Phone:228-822-6065
Mailing Address - Fax:228-822-1006
Practice Address - Street 1:4333 15TH ST STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-822-6065
Practice Address - Fax:228-822-1006
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR858009363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner