Provider Demographics
NPI:1962627125
Name:HETRICK, DONNA P (CCN)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:P
Last Name:HETRICK
Suffix:
Gender:F
Credentials:CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 FAIRWAYS CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-0236
Mailing Address - Country:US
Mailing Address - Phone:540-898-5219
Mailing Address - Fax:540-891-4050
Practice Address - Street 1:3708 FAIRWAYS CT
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-0236
Practice Address - Country:US
Practice Address - Phone:540-898-5219
Practice Address - Fax:540-891-4050
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist