Provider Demographics
NPI:1083934731
Name:HIETT, PAM J
Entity Type:Individual
Prefix:
First Name:PAM
Middle Name:J
Last Name:HIETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 BRIARCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2619
Mailing Address - Country:US
Mailing Address - Phone:573-579-9144
Mailing Address - Fax:
Practice Address - Street 1:304 S MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4920
Practice Address - Country:US
Practice Address - Phone:573-651-1687
Practice Address - Fax:573-651-8734
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116932163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant