Healthcare Provider Details

I. General information

NPI: 1629001094
Provider Name (Legal Business Name): DONNA RAE HETHCOCK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 OUTLET CENTER DR
OXNARD CA
93036-0663
US

IV. Provider business mailing address

390 CASTLETON ST
CAMARILLO CA
93012-7720
US

V. Phone/Fax

Practice location:
  • Phone: 805-604-9500
  • Fax:
Mailing address:
  • Phone: 805-388-0405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN281113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: