Individual
STEPHANIE HEATON ANDERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PNP, DNP, RNCS
Contact information
Practice address
391 EAST MAIN STREET, 1 HISTORIC HAWKINS BUILDING, CANTON, GA 30114-2712
(770) 720-6963
(770) 720-6965
Mailing address
391 EAST MAIN STREET, 1 HISTORIC HAWKINS BUILDING, CANTON, GA 30114-2712
(770) 720-6963
(770) 720-6965
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
RN173488
GA
363LF0000X
Family Nurse Practitioner
RN173488
GA
363LP0200X
Pediatric Nurse Practitioner
Primary
RN173488
GA
363LW0102X
Women's Health Nurse Practitioner
RN173488
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
495715792A
MEDICAID PROVIDER ID, STEPHANIE H. ANDERSON, PNP, APRN, NPI# 1609087972
GA
01
—
629697125A
MEDICAID PAYOR ID, NORTHSIDE CHILDREN'S PEDIATRICS CTR, NPI# 1396945515
GA
01
—
GA 54532
AUTHORIZED CONTACT REPRESENTATIVE: MICHAEL G. ANDERSON, MD (ATTENDING PHYSICIAN)
GA
Enumeration date
05/25/2007
Last updated
10/28/2011
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