=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699346023
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER COWAN PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2021
-----------------------------------------------------
Last Update Date | 07/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2703 HERITAGE LN
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-8102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-951-1768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2935 CENTER ST
-----------------------------------------------------
City | COCONUT GROVE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33133-3780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-951-1768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 11014092
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------