Provider Demographics
NPI:1972128569
Name:RIDER, HEATHER MICHELLE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:RIDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4437 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28470-4451
Mailing Address - Country:US
Mailing Address - Phone:910-754-4449
Mailing Address - Fax:
Practice Address - Street 1:4437 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4451
Practice Address - Country:US
Practice Address - Phone:910-754-4449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC72318164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse