Provider Demographics
NPI:1396815866
Name:HETTIG, JUDITH LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:LYNN
Last Name:HETTIG
Suffix:
Gender:F
Credentials:FNP
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 1437
Mailing Address - Street 2:
Mailing Address - City:MEADOW VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95722-1437
Mailing Address - Country:US
Mailing Address - Phone:916-747-7063
Mailing Address - Fax:
Practice Address - Street 1:2328 MAELEE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-2508
Practice Address - Country:US
Practice Address - Phone:916-747-7063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY306210363LF0000X
CA3439363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS66723Medicare UPIN