Basic Information
| Provider Information | |||||||||
| NPI: | 1942245824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUDDUTH | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | SUSANNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9621 RIDGETOP BLVD NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838502 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 19245 7TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | POULSBO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983707504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607823500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 03/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD00024682 | WA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 070012924 | 01 | RAILROAD MEDICARE | OTHER | 100670 | 01 | WA | LABOR & INDUSTRIES | OTHER | 1089853 | 05 | WA | MEDICAID | 1918SU | 01 | REGENCE BLUESHIELD | OTHER | BS4201187 | 01 | DEA | OTHER | 4648199 | 01 | AETNA | OTHER |