=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992372494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER MAE FUSSELL APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2021
-----------------------------------------------------
Last Update Date | 06/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 223 N MAIN ST
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32696-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-529-0477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 N MAIN ST
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32696-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11013418
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------