Provider Demographics
NPI:1437886900
Name:HETKO, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HETKO
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 1:120 FLAGSTONE DR APT 11
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-2338
Mailing Address - Country:US
Mailing Address - Phone:315-532-5911
Mailing Address - Fax:
Practice Address - Street 1:40 S RIVER RD UNIT 58
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6751
Practice Address - Country:US
Practice Address - Phone:603-626-4205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH50322251X0800X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic