Healthcare Provider Details

I. General information

NPI: 1962168252
Provider Name (Legal Business Name): HAYLEE NANETTE BLANCO LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2021
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 PIONEER DR
MILLIKEN CO
80543-3147
US

IV. Provider business mailing address

725 PIONEER DR
MILLIKEN CO
80543-3147
US

V. Phone/Fax

Practice location:
  • Phone: 970-673-3544
  • Fax:
Mailing address:
  • Phone: 970-673-3544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0002587
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: