Healthcare Provider Details

I. General information

NPI: 1770200065
Provider Name (Legal Business Name): SHANNON LYNCH RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2626 N PEREGRINE PL
BOISE ID
83702-1300
US

IV. Provider business mailing address

2626 N PEREGRINE PL
BOISE ID
83702-1300
US

V. Phone/Fax

Practice location:
  • Phone: 208-866-6215
  • Fax:
Mailing address:
  • Phone: 208-866-6215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberN-39818
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-157021
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: