Provider Demographics
NPI:1396516399
Name:PELLETIER, HEATHER LILLIAN (ABOC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LILLIAN
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-5618
Mailing Address - Country:US
Mailing Address - Phone:603-431-0515
Mailing Address - Fax:603-431-0512
Practice Address - Street 1:2460 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5618
Practice Address - Country:US
Practice Address - Phone:603-431-0515
Practice Address - Fax:603-431-0512
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH255255156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician