Provider Demographics
NPI:1720382344
Name:HAMILTON, BECKY LASHONE
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:LASHONE
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4446 HENDRICKS AVE
Mailing Address - Street 2:260
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-6369
Mailing Address - Country:US
Mailing Address - Phone:904-962-1860
Mailing Address - Fax:
Practice Address - Street 1:4446 HENDRICKS AVE
Practice Address - Street 2:260
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-6369
Practice Address - Country:US
Practice Address - Phone:904-962-1860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL685167398171W00000X
FL685167396171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL685167396Medicaid
FL685167398Medicaid