Provider Demographics
NPI:1366154957
Name:TELLER, HEATHER A (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:TELLER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5372 WILLIAM EARL WAY
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-3602
Mailing Address - Country:US
Mailing Address - Phone:804-854-1003
Mailing Address - Fax:
Practice Address - Street 1:2244 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2430
Practice Address - Country:US
Practice Address - Phone:757-827-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185805363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health