Provider Demographics
NPI:1689840456
Name:BUKOWSKI, LYNN MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:MARIE
Last Name:BUKOWSKI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1720
Mailing Address - Country:US
Mailing Address - Phone:503-281-0278
Mailing Address - Fax:
Practice Address - Street 1:2627 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1720
Practice Address - Country:US
Practice Address - Phone:503-281-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7782172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker