Provider Demographics
NPI:1427464148
Name:PETRY, HEATHER DAWN (APRN)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:DAWN
Last Name:PETRY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S B B KING BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:866-949-0108
Mailing Address - Fax:
Practice Address - Street 1:103 RANDOLPH AVE STE 193
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-4067
Practice Address - Country:US
Practice Address - Phone:669-490-1088
Practice Address - Fax:304-925-1343
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN70678363LF0000X
WV70678363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily