Provider Demographics
NPI:1184243867
Name:HAMLETT, RADENE LYNN (PN0334444)
Entity type:Individual
Prefix:
First Name:RADENE
Middle Name:LYNN
Last Name:HAMLETT
Suffix:
Gender:F
Credentials:PN0334444
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 E ELIZABETH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4052
Mailing Address - Country:US
Mailing Address - Phone:186-662-8782
Mailing Address - Fax:
Practice Address - Street 1:1124 E ELIZABETH ST STE 2
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4052
Practice Address - Country:US
Practice Address - Phone:186-662-8782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPN0334444164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0652655Medicaid