Healthcare Provider Details

I. General information

NPI: 1164191656
Provider Name (Legal Business Name): HEATHER JAYNE CARRIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 CHEVERLY DR W
LAKELAND FL
33813-1210
US

IV. Provider business mailing address

3911 CHEVERLY DR W
LAKELAND FL
33813-1210
US

V. Phone/Fax

Practice location:
  • Phone: 863-224-9095
  • Fax:
Mailing address:
  • Phone: 863-224-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11015272
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: