Provider Demographics
NPI:1578251062
Name:ZICKEFOOSE, M LYNNETTE
Entity Type:Individual
Prefix:
First Name:M
Middle Name:LYNNETTE
Last Name:ZICKEFOOSE
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 1927
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315
Mailing Address - Country:US
Mailing Address - Phone:900-927-3511
Mailing Address - Fax:
Practice Address - Street 1:41945 BIG BEAR BLVD
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315-2030
Practice Address - Country:US
Practice Address - Phone:900-986-6507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA688495164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse