Healthcare Provider Details

I. General information

NPI: 1427464148
Provider Name (Legal Business Name): HEATHER DAWN PETRY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 WISE RD
CONWAY SC
29526-5521
US

IV. Provider business mailing address

2404 WISE RD
CONWAY SC
29526-5521
US

V. Phone/Fax

Practice location:
  • Phone: 843-365-8884
  • Fax: 843-365-6697
Mailing address:
  • Phone: 843-365-8884
  • Fax: 843-365-6697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26858
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN70678
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number70678
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: