Provider Demographics
NPI:1730632951
Name:NANNERY, HEATHER R (NP)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:R
Last Name:NANNERY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:HEATHER
Other - Middle Name:R
Other - Last Name:NANNERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:37 DIETZ STREET
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820
Mailing Address - Country:US
Mailing Address - Phone:607-432-2252
Mailing Address - Fax:607-432-7206
Practice Address - Street 1:117 HAWLEY STREET
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901
Practice Address - Country:US
Practice Address - Phone:607-723-8306
Practice Address - Fax:607-785-9862
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340868-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4655854Medicaid