Provider Demographics
NPI:1568107308
Name:LETELLIER, EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:LETELLIER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3550
Mailing Address - Country:US
Mailing Address - Phone:509-853-1082
Mailing Address - Fax:509-452-5224
Practice Address - Street 1:1806 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2473
Practice Address - Country:US
Practice Address - Phone:509-452-4520
Practice Address - Fax:509-452-5224
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL61297470390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program