Provider Demographics
NPI:1104922236
Name:HETHKE, CELIA A (RNC, ANP, APN)
Entity type:Individual
Prefix:
First Name:CELIA
Middle Name:A
Last Name:HETHKE
Suffix:
Gender:F
Credentials:RNC, ANP, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 KENDALL ST
Mailing Address - Street 2:
Mailing Address - City:GIFFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61847-9602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 N MARKET ST
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:IL
Practice Address - Zip Code:60957-1123
Practice Address - Country:US
Practice Address - Phone:217-379-4864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-171180363LA2200X
IL209-001278(41-17118)363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health