Basic Information
| Provider Information | |||||||||
| NPI: | 1619593886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMERON | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | NP -C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3065 WOOD VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302538623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046239200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 KELLY RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302536097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709571887 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2020 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN258034 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.