Provider Demographics
NPI:1831714716
Name:LAMOTT, RAELENE MARIE
Entity type:Individual
Prefix:
First Name:RAELENE
Middle Name:MARIE
Last Name:LAMOTT
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 1:3827 MONUMENT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-2170
Mailing Address - Country:US
Mailing Address - Phone:260-403-9572
Mailing Address - Fax:
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5886
Practice Address - Country:US
Practice Address - Phone:260-403-9572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27050252A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse