Basic Information
| Provider Information | |||||||||
| NPI: | 1679707079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NETTLETON | ||||||||
| FirstName: | LINDY | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERZOG | ||||||||
| OtherFirstName: | LINDY | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S, | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 NE FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413896669 | ||||||||
| FaxNumber: | 5413898865 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 NE FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302418799 | ||||||||
| FaxNumber: | 5302418798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 30869 | OR | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 500717298 | 05 | OR | MEDICAID |