Provider Demographics
NPI:1275334831
Name:DETAMORE, MADISON SUE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:SUE
Last Name:DETAMORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-1625
Mailing Address - Country:US
Mailing Address - Phone:308-850-3138
Mailing Address - Fax:
Practice Address - Street 1:1100 BENTON ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-1625
Practice Address - Country:US
Practice Address - Phone:308-850-3138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant