Provider Demographics
NPI:1003651340
Name:HUMPHRIES, SALLY LYNNETTE (LPN)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:LYNNETTE
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 NE 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-4360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1622 NE 9TH AVE
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-4360
Practice Address - Country:US
Practice Address - Phone:971-940-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00055742164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse