Healthcare Provider Details

I. General information

NPI: 1841284544
Provider Name (Legal Business Name): LYNN D WILLE ATC/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 FRANKLIN AVE SUITE LL2
GARDEN CITY NY
11530-1886
US

IV. Provider business mailing address

23 MASSACHUSETTS BLVD
FLORAL PARK NY
11001-4138
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-9099
  • Fax: 516-663-9092
Mailing address:
  • Phone: 516-328-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000973
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: