Provider Demographics
NPI:1629001094
Name:HETHCOCK, DONNA RAE (RN)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:RAE
Last Name:HETHCOCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 CASTLETON ST
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-7720
Mailing Address - Country:US
Mailing Address - Phone:805-388-0405
Mailing Address - Fax:
Practice Address - Street 1:1901 OUTLET CENTER DR
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0663
Practice Address - Country:US
Practice Address - Phone:805-604-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN281113163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care