Basic Information
Provider Information | |||||||||
NPI: | 1053997254 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LULL | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | LEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | IBCLC, LMT,CST,DOULA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2200 NE PROFESSIONAL CT | ||||||||
Address2: |   | ||||||||
City: | BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 977016063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413896313 | ||||||||
FaxNumber: | 5413898760 | ||||||||
Practice Location | |||||||||
Address1: | 2200 NE PROFESSIONAL CT | ||||||||
Address2: |   | ||||||||
City: | BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 977016063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413896313 | ||||||||
FaxNumber: | 5413898760 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2021 | ||||||||
LastUpdateDate: | 05/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 26277 | OR | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   | 174N00000X | LC-LC-10214114 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Lactation Consultant, Non-RN |   |
No ID Information.