Provider Demographics
NPI:1760599609
Name:PATTULLO, JEWELENE RAE
Entity Type:Individual
Prefix:MRS
First Name:JEWELENE
Middle Name:RAE
Last Name:PATTULLO
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JEWELENE
Other - Middle Name:RAE
Other - Last Name:HENLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4805 NE 52ND CIR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7805
Mailing Address - Country:US
Mailing Address - Phone:360-695-4912
Mailing Address - Fax:
Practice Address - Street 1:14406 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1448
Practice Address - Country:US
Practice Address - Phone:360-418-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00001723156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician