Provider Demographics
NPI:1023896842
Name:WEATHERSPOON, HEATHER
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:
Last Name:WEATHERSPOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 E NORTHSIDE DR APT 2225
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76106-8426
Mailing Address - Country:US
Mailing Address - Phone:817-803-5045
Mailing Address - Fax:817-549-5376
Practice Address - Street 1:4455 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3864
Practice Address - Country:US
Practice Address - Phone:817-803-5045
Practice Address - Fax:817-549-5376
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)