Provider Demographics
NPI:1659460889
Name:HETLAND, NANCY LYNN (OD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:LYNN
Last Name:HETLAND
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2848 DAILEY DR
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-5209
Mailing Address - Country:US
Mailing Address - Phone:605-292-0648
Mailing Address - Fax:
Practice Address - Street 1:1900 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-1160
Practice Address - Country:US
Practice Address - Phone:605-996-7042
Practice Address - Fax:605-996-6627
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL-9397OtherEYEMED PROVIDER NUMBER
IL0040030744OtherBCBS PROVIDER NUMBER