Healthcare Provider Details

I. General information

NPI: 1033241476
Provider Name (Legal Business Name): EDNA JANE HEATH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

987 ST SEBASTIAN WAY - EC4350
AUGUSTA GA
30912
US

IV. Provider business mailing address

3517 STEVENS WAY
MARTINEZ GA
30907-9564
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-0422
  • Fax:
Mailing address:
  • Phone: 706-210-7425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN131105
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: