Healthcare Provider Details

I. General information

NPI: 1760457485
Provider Name (Legal Business Name): PAMELA HETHERINGTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 COLUMBUS AVE
NEW HAVEN CT
06519-1233
US

IV. Provider business mailing address

400 COLUMBUS AVE
NEW HAVEN CT
06519-1233
US

V. Phone/Fax

Practice location:
  • Phone: 203-503-3250
  • Fax: 203-503-3254
Mailing address:
  • Phone: 203-503-3250
  • Fax: 203-503-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036588
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036588
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: