Provider Demographics
NPI:1962168252
Name:BLANCO, HAYLEE NANETTE (LAT, ATC)
Entity type:Individual
Prefix:
First Name:HAYLEE
Middle Name:NANETTE
Last Name:BLANCO
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 PIONEER DR
Mailing Address - Street 2:
Mailing Address - City:MILLIKEN
Mailing Address - State:CO
Mailing Address - Zip Code:80543-3147
Mailing Address - Country:US
Mailing Address - Phone:970-673-3544
Mailing Address - Fax:
Practice Address - Street 1:725 PIONEER DR
Practice Address - Street 2:
Practice Address - City:MILLIKEN
Practice Address - State:CO
Practice Address - Zip Code:80543-3147
Practice Address - Country:US
Practice Address - Phone:970-673-3544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00025872255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer