1083971147 NPI number — LYNETTE VICTORIA MARSHALL ARNP

Table of content: TYLER GLOVER (NPI 1053028944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083971147 NPI number — LYNETTE VICTORIA MARSHALL ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARSHALL
Provider First Name:
LYNETTE
Provider Middle Name:
VICTORIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083971147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 S 5TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98902-3550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-494-6700
Provider Business Mailing Address Fax Number:
509-573-6275

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51781 HUNTINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PINE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97739-1118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-907-7040
Provider Business Practice Location Address Fax Number:
541-907-7059
Provider Enumeration Date:
04/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP60296830 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: RN001106896 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2021778 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: RN00106896 . This is a "RN LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: AP60296830 . This is a "ARNP LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0417847 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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