Provider Demographics
NPI:1114285376
Name:PETIBONE, LYNETTE MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:LYNETTE
Middle Name:MICHELLE
Last Name:PETIBONE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LYNETTE
Other - Middle Name:MICHELLE
Other - Last Name:PETTIBONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LM, LDM, CPM
Mailing Address - Street 1:14104 SW 121ST AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2818
Mailing Address - Country:US
Mailing Address - Phone:503-443-6902
Mailing Address - Fax:
Practice Address - Street 1:14104 SW 121ST AVE
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-2818
Practice Address - Country:US
Practice Address - Phone:503-443-6902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP301374J00000X
ORDEM-LD-10182635176B00000X
WAMW60719565176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No374J00000XNursing Service Related ProvidersDoula