MEDICARE: LAURA JEAN HETTRICH NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	F303030-1	NY

General Provider Information

NPI Number	:	1659486710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA JEAN HETTRICH NP

Provider Business Mailing Address
First Line	:	PO BOX 1559
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11790-0989
Country	:	US
Telephone Number	:	631-444-0650
Fax Number	:	631-638-4170

Provider Business Practice Location Address
First Line	:	STONY BROOK HOSPITAL HSC T19 020
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11794-8191
Country	:	US
Telephone Number	:	631-444-0650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	12/12/2016

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