Provider Demographics
NPI:1487249306
Name:HESKETT, TIA (APRN)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:HESKETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 FAIRFAX RD
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-7505
Mailing Address - Country:US
Mailing Address - Phone:573-717-6913
Mailing Address - Fax:
Practice Address - Street 1:225 PHYSICIANS PARK STE 203
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3921
Practice Address - Country:US
Practice Address - Phone:475-057-3686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020018542363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020018542OtherAPRN LICENSE NUMBER
AR213455OtherARKANSAS APRN LICENSE NUMBER