Provider Demographics
NPI:1083070825
Name:HETLAND, LEA (RN, CRNA)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:HETLAND
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:10 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9554
Practice Address - Country:US
Practice Address - Phone:707-963-3611
Practice Address - Fax:707-967-5622
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-09
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9500045367500000X
CANA95000445367500000X
CARN728662163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA194881Medicare PIN