Healthcare Provider Details

I. General information

NPI: 1467442277
Provider Name (Legal Business Name): ANDREA K LYNCH ATC/L
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 MAR WALT DR SUITE 104
FT WALTON BEACH FL
32547-6706
US

IV. Provider business mailing address

611 CROWDER CT
FT WALTON BEACH FL
32547-3624
US

V. Phone/Fax

Practice location:
  • Phone: 850-218-0210
  • Fax:
Mailing address:
  • Phone: 850-863-1109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL1646
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: