Provider Demographics
NPI:1962625996
Name:BISSONNETTE, LYNNE B (MD,PHD)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:B
Last Name:BISSONNETTE
Suffix:
Gender:F
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 NW FLANDERS ST STE 306
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5411
Mailing Address - Country:US
Mailing Address - Phone:503-226-0558
Mailing Address - Fax:
Practice Address - Street 1:2250 NW FLANDERS ST STE 306
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5411
Practice Address - Country:US
Practice Address - Phone:503-226-0558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR104912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry