Provider Demographics
NPI:1154761575
Name:HETTEMA, DIANE F (LPN)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:F
Last Name:HETTEMA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07480-2108
Mailing Address - Country:US
Mailing Address - Phone:973-728-8506
Mailing Address - Fax:
Practice Address - Street 1:140 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST MILFORD
Practice Address - State:NJ
Practice Address - Zip Code:07480-2108
Practice Address - Country:US
Practice Address - Phone:973-728-8506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-29
Last Update Date:2013-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3136781164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse