1285764043 NPI number — MRS. LYNNLEE FULLENWIDER OTR L CHT

Table of content: MRS. LYNNLEE FULLENWIDER OTR L CHT (NPI 1285764043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285764043 NPI number — MRS. LYNNLEE FULLENWIDER OTR L CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLENWIDER
Provider First Name:
LYNNLEE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR L CHT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OLIN
Provider Other First Name:
LYNNLEE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285764043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12911-120TH AVE. NE,
Provider Second Line Business Mailing Address:
SUITE F-120
Provider Business Mailing Address City Name:
KIRKLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98034-3025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-823-1389
Provider Business Mailing Address Fax Number:
425-820-3996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12911-120TH AVE. NE,
Provider Second Line Business Practice Location Address:
SUITE F-120
Provider Business Practice Location Address City Name:
KIRKLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98034-3025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-823-1389
Provider Business Practice Location Address Fax Number:
425-820-3996
Provider Enumeration Date:
03/07/2007

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: 225X00000X , with the licence number:  OT00000365 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225XH1200X , with the licence number: 9105000003 , 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: 0282315 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0282300 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0282323 . This is a "L & I" identifier . This identifiers is of the category "OTHER".
  • Identifier: 34464 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7680697 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: FU4123 . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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