Provider Demographics
NPI:1912930603
Name:FUNSTON, LEXINE (ARNP)
Entity Type:Individual
Prefix:
First Name:LEXINE
Middle Name:
Last Name:FUNSTON
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:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0146
Mailing Address - Country:US
Mailing Address - Phone:360-565-9240
Mailing Address - Fax:360-565-9241
Practice Address - Street 1:823 GEORGIANA STREET
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-0146
Practice Address - Country:US
Practice Address - Phone:360-457-4496
Practice Address - Fax:360-457-2181
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006045363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9632621Medicaid
WA9632621Medicaid