Healthcare Provider Details

I. General information

NPI: 1841351996
Provider Name (Legal Business Name): MARY E LYNCH LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1696 W MAIN CR #28
DEPERE WI
54115
US

IV. Provider business mailing address

1696 W MAIN CIR #28
DEPERE WI
54115
US

V. Phone/Fax

Practice location:
  • Phone: 920-360-4199
  • Fax:
Mailing address:
  • Phone: 920-360-4199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number818-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: