Healthcare Provider Details

I. General information

NPI: 1083523450
Provider Name (Legal Business Name): LYNETTE A IVANOV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4535 NORMAL BLVD STE 132
LINCOLN NE
68506-2891
US

IV. Provider business mailing address

4500 LOWELL AVE
LINCOLN NE
68506-4925
US

V. Phone/Fax

Practice location:
  • Phone: 402-525-1423
  • Fax:
Mailing address:
  • Phone: 402-525-1423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1076
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: