Provider Demographics
NPI:1215190798
Name:LYNAM, ROCHELLE MARIE (MPH, PA-S)
Entity Type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:MARIE
Last Name:LYNAM
Suffix:
Gender:F
Credentials:MPH, PA-S
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-414-2360
Mailing Address - Fax:
Practice Address - Street 1:211 16TH AVE N
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-4058
Practice Address - Country:US
Practice Address - Phone:208-467-4431
Practice Address - Fax:208-467-7684
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-06
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60049562363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00691526OtherRAILROAD MEDICARE
WA8528598Medicaid
OR500606345Medicaid
WA0242920OtherLABOR & INDUSTRIES
WA0242920OtherLABOR & INDUSTRIES