Healthcare Provider Details

I. General information

NPI: 1396815866
Provider Name (Legal Business Name): JUDITH LYNN HETTIG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2328 MAELEE DR
VISTA CA
92084-2508
US

IV. Provider business mailing address

PO BOX 1437
MEADOW VISTA CA
95722-1437
US

V. Phone/Fax

Practice location:
  • Phone: 916-747-7063
  • Fax:
Mailing address:
  • Phone: 916-747-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3439
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberY306210
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: