Provider Demographics
NPI:1982805347
Name:HADLOCK, TINA R (RN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:R
Last Name:HADLOCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 252
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-0252
Mailing Address - Country:US
Mailing Address - Phone:435-722-5122
Mailing Address - Fax:
Practice Address - Street 1:6822 E 1000 S
Practice Address - Street 2:
Practice Address - City:FT, DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84026-0160
Practice Address - Country:US
Practice Address - Phone:435-722-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT196798-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT196798-3102OtherREGISTERED NURSE