Provider Demographics
NPI:1639105083
Name:LYSEN-HALPERN, POLLYANN SEBRINA (ARNP)
Entity Type:Individual
Prefix:
First Name:POLLYANN
Middle Name:SEBRINA
Last Name:LYSEN-HALPERN
Suffix:
Gender:F
Credentials:ARNP
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 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:2705 NE 65TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-7129
Practice Address - Country:US
Practice Address - Phone:206-414-9992
Practice Address - Fax:206-528-6132
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00099295163W00000X
WAAP30003688363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA16381UOtherREGENCE BLUESHIELD
WA9616822Medicaid
WA0211014OtherLABOR & INDUSTRIES
WAS67899Medicare UPIN
WAG8941889Medicare UPIN
WA8861016Medicare PIN