Healthcare Provider Details

I. General information

NPI: 1629645635
Provider Name (Legal Business Name): VERONIKA MAE HETENIAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 12/15/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12660 RIVERSIDE DR STE 225
NORTH HOLLYWOOD CA
91607-3469
US

IV. Provider business mailing address

12660 RIVERSIDE DR STE 225
NORTH HOLLYWOOD CA
91607-3469
US

V. Phone/Fax

Practice location:
  • Phone: 818-755-0265
  • Fax: 818-753-9074
Mailing address:
  • Phone: 818-755-0265
  • Fax: 818-753-9074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: