1275734931 NPI number — LYNAE MICHELLE EDMONDS DNP, RN, PMHNP-BC

Table of content: LYNAE MICHELLE EDMONDS DNP, RN, PMHNP-BC (NPI 1275734931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275734931 NPI number — LYNAE MICHELLE EDMONDS DNP, RN, PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDMONDS
Provider First Name:
LYNAE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DNP, RN, PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEWIS; LIDDELL; HOOVER; MCGRATH
Provider Other First Name:
LYNAE
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275734931
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10225 NE MCKAY CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINEVILLE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97754-8270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2110 MISSION ST SE STE 305
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97302-0038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-990-3677
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2007

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: 363LP0808X , with the licence number:  10012855 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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