Provider Demographics
NPI:1629069893
Name:LIEUALLEN, LYNN MARIE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:MARIE
Last Name:LIEUALLEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2461 SW PERKINS AVE
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-4301
Mailing Address - Country:US
Mailing Address - Phone:541-276-0250
Mailing Address - Fax:541-276-0253
Practice Address - Street 1:2461 SW PERKINS AVE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-4301
Practice Address - Country:US
Practice Address - Phone:541-276-0250
Practice Address - Fax:541-276-0253
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350090NPFNPPP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297428Medicaid