Provider Demographics
NPI:1881662161
Name:DIEM, LAURIE LYNNE (DO)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:LYNNE
Last Name:DIEM
Suffix:
Gender:F
Credentials:DO
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:751 NE BLAKELY DR
Practice Address - Street 2:STE 5010
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-6201
Practice Address - Country:US
Practice Address - Phone:425-394-0700
Practice Address - Fax:425-394-0701
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7699208000000X
WAOP60270441208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX76990Medicaid
H58671Medicare UPIN
CAH58671Medicare ID - Type Unspecified