Healthcare Provider Details

I. General information

NPI: 1538162193
Provider Name (Legal Business Name): LYNN BENSON WYVILLE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNN E BENSON

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SE 136TH AVE
VANCOUVER WA
98684-6930
US

IV. Provider business mailing address

210 SE 136TH AVE
VANCOUVER WA
98684-6930
US

V. Phone/Fax

Practice location:
  • Phone: 360-944-9889
  • Fax: 360-944-9686
Mailing address:
  • Phone: 360-944-9889
  • Fax: 360-944-9686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004265
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: