Provider Demographics
NPI:1366724924
Name:WALLIN, LEE RAIN
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:RAIN
Last Name:WALLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 ARROWHEAD LOOP
Mailing Address - Street 2:
Mailing Address - City:CANADIAN
Mailing Address - State:OK
Mailing Address - Zip Code:74425-5012
Mailing Address - Country:US
Mailing Address - Phone:918-339-5800
Mailing Address - Fax:
Practice Address - Street 1:69 ARROWHEAD LOOP
Practice Address - Street 2:
Practice Address - City:CANADIAN
Practice Address - State:OK
Practice Address - Zip Code:74425-5012
Practice Address - Country:US
Practice Address - Phone:918-339-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker