Provider Demographics
NPI:1962466920
Name:HETHERINGTON, PAIGE E
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:E
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 1:711 1/2 PIER AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2507
Practice Address - Country:US
Practice Address - Phone:310-451-2209
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9664171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist