Provider Demographics
NPI:1467458869
Name:POULSEN, LINDSEY C (PA-C)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:C
Last Name:POULSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LINDSEY
Other - Middle Name:C
Other - Last Name:WELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1491 VALLE VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6241
Mailing Address - Country:US
Mailing Address - Phone:309-347-4277
Mailing Address - Fax:309-347-4388
Practice Address - Street 1:1491 VALLE VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6241
Practice Address - Country:US
Practice Address - Phone:309-347-4277
Practice Address - Fax:309-347-4388
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209498Medicare ID - Type Unspecified
P51373Medicare UPIN