Provider Demographics
NPI:1538102603
Name:HETHERINGTON, JUDY LYN (CRNP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:LYN
Last Name:HETHERINGTON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:JUDY
Other - Middle Name:LYN
Other - Last Name:WENINGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:443-997-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR131559363L00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD699815100Medicaid
MDC31152OtherR/R MEDICARE GROUP #
MDP00123941OtherR/R MEDICARE PROVIDER #
MD699815100Medicaid
MDK510C380Medicare PIN
MDP00123941OtherR/R MEDICARE PROVIDER #