Basic Information
| Provider Information | |||||||||
| NPI: | 1407268857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FETTY | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Practice Location | |||||||||
| Address1: | 939 CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605659003 | ||||||||
| FaxNumber: | 3605659001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2014 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 71514-20 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | MD61038016 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0427056 | 01 | WA | L&I-VANCOUVER RADIOLOGY | OTHER | 0426796 | 01 | WA | L&I-RADIA REST OF WA | OTHER | 0426800 | 01 | WA | L&I-EVERGREEN RADIA | OTHER | 2160014 | 05 | WA | MEDICAID | 0426798 | 01 | WA | L&I-RADIA KING CTY | OTHER | 0426797 | 01 | WA | L&I-SWEDISH RADIA EDMONDS | OTHER | 0426804 | 01 | WA | L&I-SOUTH SOUND RADIOLOGY | OTHER | 0426805 | 01 | WA | L&I-SEATTE RADIOLOGY | OTHER |