MEDICARE: HEATHER REAGAN AFNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP145154	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AP145154	OTHER	TX	TEXAS BOARD OF NURSING

General Provider Information

NPI Number	:	1326671231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER REAGAN AFNP

Provider Business Mailing Address
First Line	:	1273 S PEACHTREE ST
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-4915
Country	:	US
Telephone Number	:	409-384-9200
Fax Number	:	409-384-9205

Provider Business Practice Location Address
First Line	:	1273 S PEACHTREE ST
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-4915
Country	:	US
Telephone Number	:	409-384-9200
Fax Number	:	409-384-9205

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2020
Last Update Date	:	01/12/2021

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