Provider Demographics
NPI:1528362340
Name:MAHLUM, LYNSEY BRIANE (ARNP)
Entity Type:Individual
Prefix:
First Name:LYNSEY
Middle Name:BRIANE
Last Name:MAHLUM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LYNSEY
Other - Middle Name:BRIANE
Other - Last Name:RIDOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1405 SOUTH 8TH AVENUE
Mailing Address - Street 2:BANNER HEALTH CLINIC SURGICAL SPECIALTIES
Mailing Address - City:STERLING
Mailing Address - State:CO
Mailing Address - Zip Code:80751
Mailing Address - Country:US
Mailing Address - Phone:970-526-8123
Mailing Address - Fax:
Practice Address - Street 1:1801 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5154
Practice Address - Country:US
Practice Address - Phone:970-350-6953
Practice Address - Fax:970-350-6965
Is Sole Proprietor?:No
Enumeration Date:2011-01-08
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60192019363L00000X
COAPN.0991119-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1528362340Medicaid