Basic Information
| Provider Information | |||||||||
| NPI: | 1013052497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHASTAIN | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | COFFEEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP - C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COFFEEN | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 120-B OSIGIAN BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310888939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789535358 | ||||||||
| FaxNumber: | 4789535340 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 CORDER RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310883606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789223074 | ||||||||
| FaxNumber: | 4789223076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 150125 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.