Healthcare Provider Details

I. General information

NPI: 1124221734
Provider Name (Legal Business Name): JUDITH ELAINE LYNCH RD, PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2007
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 NOBLES FERRY RD
LIVE OAK FL
32064-8463
US

IV. Provider business mailing address

1150 US HIGHWAY 41 NW SUITE 11 & 12
JASPER FL
32052-5888
US

V. Phone/Fax

Practice location:
  • Phone: 386-364-1751
  • Fax: 386-364-1761
Mailing address:
  • Phone: 386-792-7744
  • Fax: 386-792-7745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9105408
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND5728
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: