Provider Demographics
NPI:1942907506
Name:FOCKEN, LYNAE WHITNEY
Entity Type:Individual
Prefix:
First Name:LYNAE
Middle Name:WHITNEY
Last Name:FOCKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8506 KING ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-1284
Mailing Address - Country:US
Mailing Address - Phone:402-658-2020
Mailing Address - Fax:
Practice Address - Street 1:8506 KING ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-1284
Practice Address - Country:US
Practice Address - Phone:402-658-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA117AM5605OtherDRIVERS LICENSE