Provider Demographics
NPI:1285764043
Name:FULLENWIDER, LYNNLEE (OTR L CHT)
Entity type:Individual
Prefix:MRS
First Name:LYNNLEE
Middle Name:
Last Name:FULLENWIDER
Suffix:
Gender:F
Credentials:OTR L CHT
Other - Prefix:MS
Other - First Name:LYNNLEE
Other - Middle Name:
Other - Last Name:OLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR L
Mailing Address - Street 1:12911-120TH AVE. NE,
Mailing Address - Street 2:SUITE F-120
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3025
Mailing Address - Country:US
Mailing Address - Phone:425-823-1389
Mailing Address - Fax:425-820-3996
Practice Address - Street 1:12911-120TH AVE. NE,
Practice Address - Street 2:SUITE F-120
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3025
Practice Address - Country:US
Practice Address - Phone:425-823-1389
Practice Address - Fax:425-820-3996
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00000365225X00000X
WA9105000003225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0282315OtherL & I
WA0282300OtherL & I
0282323OtherL & I
WA34464OtherL & I
WA7680697Medicaid
WAFU4123OtherREGENCE
WAFU4123OtherREGENCE
AB33145Medicare PIN
WA0282315OtherL & I
WAAB33145Medicare ID - Type Unspecified
WAG8906206Medicare PIN
WAG8902276Medicare PIN