Healthcare Provider Details

I. General information

NPI: 1184549693
Provider Name (Legal Business Name): HERITAGE MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 BEN LOMAND DR STE B
SPARTA TN
38583-1592
US

IV. Provider business mailing address

521 BEN LOMAND DR STE B
SPARTA TN
38583-1592
US

V. Phone/Fax

Practice location:
  • Phone: 931-265-4292
  • Fax:
Mailing address:
  • Phone: 931-265-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY DAWN WAGNER
Title or Position: OWNER
Credential: FNP-BC
Phone: 931-265-4292