Healthcare Provider Details

I. General information

NPI: 1770065922
Provider Name (Legal Business Name): LYNISE PERRY CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 INDEPENDENCE PKWY STE 240
CHESAPEAKE VA
23320-5222
US

IV. Provider business mailing address

557 RIVER CREEK RD
CHESAPEAKE VA
23320-6233
US

V. Phone/Fax

Practice location:
  • Phone: 234-564-3726
  • Fax:
Mailing address:
  • Phone: 234-564-3726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX4713
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: