Provider Demographics
NPI:1104995273
Name:WACHHOLZ, LYNETTE M (ARNP)
Entity type:Individual
Prefix:
First Name:LYNETTE
Middle Name:M
Last Name:WACHHOLZ
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 HOYT AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4918
Mailing Address - Country:US
Mailing Address - Phone:425-258-3903
Mailing Address - Fax:
Practice Address - Street 1:4410 106TH ST SW
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-4700
Practice Address - Country:US
Practice Address - Phone:425-388-6002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002206363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
001200726Medicare PIN
A22514Medicare UPIN