Healthcare Provider Details

I. General information

NPI: 1285764043
Provider Name (Legal Business Name): LYNNLEE FULLENWIDER OTR L CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNNLEE OLIN OTR L

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12911-120TH AVE. NE, SUITE F-120
KIRKLAND WA
98034-3025
US

IV. Provider business mailing address

12911-120TH AVE. NE, SUITE F-120
KIRKLAND WA
98034-3025
US

V. Phone/Fax

Practice location:
  • Phone: 425-823-1389
  • Fax: 425-820-3996
Mailing address:
  • Phone: 425-823-1389
  • Fax: 425-820-3996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT00000365
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number9105000003
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: