1194775973 NPI number — LYNNE D WILLETT M.D.

Table of content: LYNNE D WILLETT M.D. (NPI 1194775973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194775973 NPI number — LYNNE D WILLETT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLETT
Provider First Name:
LYNNE
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1194775973
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8200 DODGE ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-955-6140
Provider Business Mailing Address Fax Number:
402-955-3398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8200 DODGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-955-6140
Provider Business Practice Location Address Fax Number:
402-955-3398
Provider Enumeration Date:
05/11/2006

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: 2080N0001X , with the licence number:  2001014481 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 136780001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202554812 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64068919 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 370020196 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 466289 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 148069 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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