Provider Demographics
NPI:1134594179
Name:PICKETT, LYNNETTE LATRICE
Entity type:Individual
Prefix:MRS
First Name:LYNNETTE
Middle Name:LATRICE
Last Name:PICKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LYNNETTE
Other - Middle Name:LATRICE
Other - Last Name:AYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4419 MARQUETTE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-4623
Mailing Address - Country:US
Mailing Address - Phone:260-580-4954
Mailing Address - Fax:
Practice Address - Street 1:4419 MARQUETTE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-4623
Practice Address - Country:US
Practice Address - Phone:260-580-4954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001668A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant