Healthcare Provider Details

I. General information

NPI: 1700197977
Provider Name (Legal Business Name): HEATHER ELIZABETH WATERS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER ELIZABETH WHITE AULTMAN

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

596 W 11TH AVE
LUMBERTON MS
39455-2350
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 601-596-4215
  • Fax: 601-796-9437
Mailing address:
  • Phone: 601-545-8700
  • Fax: 601-255-2645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21796
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: