Provider Demographics
NPI:1205985587
Name:FOSSUM, LYNELLE A (ARNP)
Entity type:Individual
Prefix:
First Name:LYNELLE
Middle Name:A
Last Name:FOSSUM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:KS
Mailing Address - Zip Code:67748-1220
Mailing Address - Country:US
Mailing Address - Phone:785-672-3261
Mailing Address - Fax:785-672-8194
Practice Address - Street 1:212 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:OAKLEY
Practice Address - State:KS
Practice Address - Zip Code:67748-1220
Practice Address - Country:US
Practice Address - Phone:785-672-3261
Practice Address - Fax:785-672-8194
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45996363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100099230FMedicaid
KS200420290DMedicaid
KS16261OtherPREFERRED HEALTH SYSTEMS
KS16261OtherPREFERRED HEALTH SYSTEMS
KS178562Medicare PIN
KS178562Medicare PIN