Healthcare Provider Details

I. General information

NPI: 1417547886
Provider Name (Legal Business Name): KAYLEEN ELIZABETH LYNCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLEEN ELIZABETH LYNCH PA-C

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 02/10/2023
Certification Date: 03/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR STE 900
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

8081 INNOVATION PARK DR STE 900
FAIRFAX VA
22031-4867
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-4200
  • Fax: 571-472-4201
Mailing address:
  • Phone: 571-472-4200
  • Fax: 571-472-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007671
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: