Provider Demographics
NPI:1851522890
Name:HETHERINGTON, BERNICE
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:
Last Name:HETHERINGTON
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:PO BOX 60102
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99706-0102
Mailing Address - Country:US
Mailing Address - Phone:907-452-8251
Mailing Address - Fax:907-459-3810
Practice Address - Street 1:122 1ST AVE STE 400
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4871
Practice Address - Country:US
Practice Address - Phone:907-459-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid