Provider Demographics
NPI:1497400162
Name:LYNETTE M PETTIBONE, LDM, LLC
Entity Type:Organization
Organization Name:LYNETTE M PETTIBONE, LDM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:PETIBONE
Authorized Official - Suffix:
Authorized Official - Credentials:LM, CPM
Authorized Official - Phone:503-443-6902
Mailing Address - Street 1:7720 NE HIGHWAY 99 # D441
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8858
Mailing Address - Country:US
Mailing Address - Phone:206-552-0061
Mailing Address - Fax:844-822-7441
Practice Address - Street 1:3300 NE 54TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-1953
Practice Address - Country:US
Practice Address - Phone:206-552-0061
Practice Address - Fax:844-822-7441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty