Healthcare Provider Details

I. General information

NPI: 1124348610
Provider Name (Legal Business Name): LYNN P HILLERY/LIVE WELL WITH LYNN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 SOUTHAVEN AVE STE 2
MEDFORD NY
11763-3745
US

IV. Provider business mailing address

25 ANDREA LN
WEST SAYVILLE NY
11796-1515
US

V. Phone/Fax

Practice location:
  • Phone: 631-343-2024
  • Fax: 631-343-2024
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number006087-1
License Number StateNY

VIII. Authorized Official

Name: LYNN P HILLERY
Title or Position: OWNER
Credential: RD
Phone: 631-921-1100