Provider Demographics
NPI:1780492728
Name:HETHERSHAW, ANNELIESE
Entity type:Individual
Prefix:MRS
First Name:ANNELIESE
Middle Name:
Last Name:HETHERSHAW
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 1:1571 AMBERLEA DR S
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-4600
Mailing Address - Country:US
Mailing Address - Phone:727-385-6928
Mailing Address - Fax:
Practice Address - Street 1:1571 AMBERLEA DR S
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-4600
Practice Address - Country:US
Practice Address - Phone:727-385-6928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11036011363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily