Provider Demographics
NPI:1003838954
Name:HETHERINGTON, TERESE (CRNP)
Entity Type:Individual
Prefix:
First Name:TERESE
Middle Name:
Last Name:HETHERINGTON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SPRUCE ST
Mailing Address - Street 2:STE. 304
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4022
Mailing Address - Country:US
Mailing Address - Phone:215-829-3521
Mailing Address - Fax:
Practice Address - Street 1:700 SPRUCE ST
Practice Address - Street 2:STE. 304
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-4022
Practice Address - Country:US
Practice Address - Phone:215-829-3521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP004062B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S62072Medicare UPIN
015617Medicare ID - Type Unspecified