Healthcare Provider Details

I. General information

NPI: 1033754064
Provider Name (Legal Business Name): KATELYN LANNING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATELYN PADDOCK

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 PACIFIC PL
MOUNT VERNON WA
98273-5463
US

IV. Provider business mailing address

320 PACIFIC PL
MOUNT VERNON WA
98273-5463
US

V. Phone/Fax

Practice location:
  • Phone: 360-416-7570
  • Fax: 360-416-7580
Mailing address:
  • Phone: 360-416-7570
  • Fax: 360-416-7580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOC61161445
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: