Healthcare Provider Details

I. General information

NPI: 1104811660
Provider Name (Legal Business Name): PATRICIA AZZARELLI LYNCH CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 N WALL ST STE P410
KANKAKEE IL
60901-3483
US

IV. Provider business mailing address

375 N WALL ST STE P410
KANKAKEE IL
60901-3483
US

V. Phone/Fax

Practice location:
  • Phone: 815-932-7474
  • Fax: 815-937-8206
Mailing address:
  • Phone: 815-932-7474
  • Fax: 815-937-8206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number309001044
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: