Provider Demographics
NPI:1467820209
Name:BADGETT, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BADGETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 WHITING ST APT 9
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-7557
Mailing Address - Country:US
Mailing Address - Phone:916-751-8764
Mailing Address - Fax:
Practice Address - Street 1:536 WHITING ST APT 9
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7557
Practice Address - Country:US
Practice Address - Phone:916-751-8764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA167388164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse