Provider Demographics
NPI:1760405948
Name:RICHARDSON, LYNETTE J (CRNA)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:J
Last Name:RICHARDSON
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:PO BOX 668
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80001-0668
Mailing Address - Country:US
Mailing Address - Phone:303-422-9438
Mailing Address - Fax:303-422-9474
Practice Address - Street 1:55 MADISON ST STE 200
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-5420
Practice Address - Country:US
Practice Address - Phone:303-388-9805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO123553367500000X
SDCR000396367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07532229Medicaid
IA720078Medicaid
SD4994175OtherBLUE CROSS SD
MN057H0LUOtherBLUE CROSS MN
SD5752110Medicaid
IA720078Medicaid
COCO544958Medicare PIN