MEDICARE: MS. PATRICIA HEASTY WHNP

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	363LW0102X	Women's Health Nurse Practitioner	940048	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2599199A	OTHER	NC	MEDICARE

General Provider Information

NPI Number	:	1407847940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PATRICIA HEASTY WHNP

Provider Business Mailing Address
First Line	:	4414 LAKE BOONE TRL
Second Line	:	STE 205
City	:	RALEIGH
State	:	NC
Zip	:	27607-7513
Country	:	US
Telephone Number	:	919-788-4444
Fax Number	:	919-788-4464

Provider Business Practice Location Address
First Line	:	4414 LAKE BOONE TRL
Second Line	:	STE 205
City	:	RALEIGH
State	:	NC
Zip	:	27607-7513
Country	:	US
Telephone Number	:	919-788-4444
Fax Number	:	919-788-4464

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

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	06/04/2012

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