Provider Demographics
NPI:1962932152
Name:MADDOX, CRICKETT RENEE (RN)
Entity type:Individual
Prefix:
First Name:CRICKETT
Middle Name:RENEE
Last Name:MADDOX
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 1:4121 HESSELTINE RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99181-9646
Mailing Address - Country:US
Mailing Address - Phone:509-380-7043
Mailing Address - Fax:
Practice Address - Street 1:4121 HESSELTINE RD
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99181-9646
Practice Address - Country:US
Practice Address - Phone:509-380-7043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60354027163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMADDOCR208LQOtherDRIVER'S LICENSE
WARN60354027OtherREGISTERED NURSE