Provider Demographics
NPI:1881016319
Name:HATHAWAY, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:HATHAWAY
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 1:4205 E TOWNLINE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-9240
Mailing Address - Country:US
Mailing Address - Phone:989-630-0019
Mailing Address - Fax:
Practice Address - Street 1:209 E CHIPPEWA ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-1609
Practice Address - Country:US
Practice Address - Phone:989-772-1261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703089945164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse