Healthcare Provider Details

I. General information

NPI: 1114980042
Provider Name (Legal Business Name): HEIDI D PRATT D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 S MAIN ST
WATER VALLEY MS
38965-3468
US

IV. Provider business mailing address

PO BOX 728
WATER VALLEY MS
38965-0728
US

V. Phone/Fax

Practice location:
  • Phone: 662-473-1311
  • Fax: 662-473-2489
Mailing address:
  • Phone: 662-473-1311
  • Fax: 662-473-2489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS9122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: