Provider Demographics
NPI:1124562442
Name:BOTTINEAU, LYDA JENEE (RN)
Entity Type:Individual
Prefix:MS
First Name:LYDA
Middle Name:JENEE
Last Name:BOTTINEAU
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:LYDA
Other - Middle Name:JENEE
Other - Last Name:HAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:217 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-5106
Mailing Address - Country:US
Mailing Address - Phone:509-627-9996
Mailing Address - Fax:
Practice Address - Street 1:217 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337-5106
Practice Address - Country:US
Practice Address - Phone:509-627-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00157282163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse