Provider Demographics
NPI:1245494129
Name:RICKETTS, WADE DEAN (LPN)
Entity type:Individual
Prefix:MR
First Name:WADE
Middle Name:DEAN
Last Name:RICKETTS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:WADE
Other - Middle Name:DEAN
Other - Last Name:SUMAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15840 E MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-2538
Mailing Address - Country:US
Mailing Address - Phone:720-233-0479
Mailing Address - Fax:
Practice Address - Street 1:15840 E MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-2538
Practice Address - Country:US
Practice Address - Phone:720-233-0479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41928164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse