Healthcare Provider Details

I. General information

NPI: 1801203773
Provider Name (Legal Business Name): LYNETTE BLOMBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2014
Last Update Date: 07/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S SANTA FE AVE
SALINA KS
67401-4144
US

IV. Provider business mailing address

PO BOX 428
LINDSBORG KS
67456-0428
US

V. Phone/Fax

Practice location:
  • Phone: 785-452-7834
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number13-15205-062
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-44340-062
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: