Provider Demographics
NPI:1154503688
Name:PLETTNER, LYNDA J
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:J
Last Name:PLETTNER
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:PO BOX 299136
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99629-9136
Mailing Address - Country:US
Mailing Address - Phone:907-892-6944
Mailing Address - Fax:907-892-6945
Practice Address - Street 1:12528 HAWK LANE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:AK
Practice Address - Zip Code:99694-2528
Practice Address - Country:US
Practice Address - Phone:907-892-6944
Practice Address - Fax:907-892-6945
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKRL7898320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHC78981Medicaid