Provider Demographics
NPI:1790944569
Name:DULLUM, LESLI LYNN (LMP RC)
Entity Type:Individual
Prefix:
First Name:LESLI
Middle Name:LYNN
Last Name:DULLUM
Suffix:
Gender:F
Credentials:LMP RC
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 600
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-0600
Mailing Address - Country:US
Mailing Address - Phone:360-509-0345
Mailing Address - Fax:360-692-6339
Practice Address - Street 1:6900 RANGER WAY
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383
Practice Address - Country:US
Practice Address - Phone:360-509-0345
Practice Address - Fax:360-692-6339
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00015680172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker