Provider Demographics
NPI:1528422490
Name:TAILLAC, HEATHER (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:TAILLAC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 S GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2205
Mailing Address - Country:US
Mailing Address - Phone:901-759-3100
Mailing Address - Fax:901-759-3196
Practice Address - Street 1:335 W SPRING ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3125
Practice Address - Country:US
Practice Address - Phone:504-842-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN66276207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ078896Medicaid