Provider Demographics
NPI:1538219084
Name:HETHERINGTON, JAN (CRNA)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:HETHERINGTON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6009 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-2201
Mailing Address - Country:US
Mailing Address - Phone:410-372-0563
Mailing Address - Fax:410-372-0564
Practice Address - Street 1:10751 FALLS RD
Practice Address - Street 2:FALLS ROAD CONCOURSE SUITE 425
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4517
Practice Address - Country:US
Practice Address - Phone:410-583-2760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD34208367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD089SMedicare ID - Type Unspecified