Provider Demographics
NPI:1750756557
Name:SOUTHWICK, HEATHER MAY (MS, AG-ACNP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MAY
Last Name:SOUTHWICK
Suffix:
Gender:F
Credentials:MS, AG-ACNP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MAY
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4330 ESTATE DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-9733
Mailing Address - Country:US
Mailing Address - Phone:410-703-3284
Mailing Address - Fax:
Practice Address - Street 1:4330 ESTATE DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTOWN
Practice Address - State:MD
Practice Address - Zip Code:20639-9733
Practice Address - Country:US
Practice Address - Phone:410-703-3284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1037248363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care