Provider Demographics
NPI:1093988057
Name:HETHERINGTON, JULIE
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:
Last Name:HETHERINGTON
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 1:805 ATLANTIC ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-6805
Mailing Address - Country:US
Mailing Address - Phone:203-327-5111
Mailing Address - Fax:203-332-0376
Practice Address - Street 1:805 ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-6805
Practice Address - Country:US
Practice Address - Phone:203-327-5111
Practice Address - Fax:203-332-0376
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001029363L00000X
MA241904363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400012193Medicare PIN