Provider Demographics
NPI:1790944049
Name:REDMON, COLLETTA LAVINA
Entity Type:Individual
Prefix:MRS
First Name:COLLETTA
Middle Name:LAVINA
Last Name:REDMON
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 1:2238 TARAS TRACE DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-8296
Mailing Address - Country:US
Mailing Address - Phone:704-883-9621
Mailing Address - Fax:
Practice Address - Street 1:2238 TARAS TRACE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-8296
Practice Address - Country:US
Practice Address - Phone:704-883-9621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0000000163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical