Provider Demographics
NPI:1588872576
Name:GOURDIN, HEATHER R (ARNP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:R
Last Name:GOURDIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1327
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03247-1327
Mailing Address - Country:US
Mailing Address - Phone:603-524-3211
Mailing Address - Fax:603-527-7038
Practice Address - Street 1:80 HIGHLAND STREET
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3235
Practice Address - Country:US
Practice Address - Phone:603-524-5151
Practice Address - Fax:603-527-7184
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH036635-23363LN0000X
AZAP4716364SN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003143602BMedicaid
FL010583800Medicaid
GA003143602BMedicaid
R59672Medicare UPIN