Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | DEM-LD-10182635 | OR |
N | 176B00000X | Midwife | MW60719565 | WA |
NPI | 1114285376 |
---|---|
Provider Name | Mrs. Lynette Michelle Petibone |
First Address | Tigard, OR 97224-2818 |
Second Address | Tigard, OR 97224-2818 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2012 |
Last Update Date | 12/04/2017 |