Provider Demographics
NPI:1841801479
Name:HAMILTON, MERCEDES SAMANTHA (LPT)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:SAMANTHA
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18465 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18465 GRAND AVE
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530
Practice Address - Country:US
Practice Address - Phone:909-753-5483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40267167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes167G00000XNursing Service ProvidersLicensed Psychiatric TechnicianGroup - Single Specialty