Healthcare Provider Details

I. General information

NPI: 1902376015
Provider Name (Legal Business Name): STACIE MARIE LYNCH RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2018
Last Update Date: 12/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MINTURN RD
WARWICK NY
10990-2610
US

IV. Provider business mailing address

75 CRYSTAL RUN RD STE 201
MIDDLETOWN NY
10941-7010
US

V. Phone/Fax

Practice location:
  • Phone: 201-741-5895
  • Fax:
Mailing address:
  • Phone: 845-692-4391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86059241
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: