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General NPI Number Information
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NPI Number | 1639707748
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Entity Type | Individual
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Provider Name | MS. LYNN WIWANTO
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Gender | Female
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Dates
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Enumeration Date | 04/01/2020
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Last Update Date | 04/09/2024
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Provider Practice Location Address
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Address Line | 23 WARREN AVE STE 100
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City | WOBURN
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State | MA
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Zip | 01801-4979
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Country | US
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Telephone | 781-933-1198
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Fax |
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Provider Business Mailing Address
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Address Line | 1493 CAMBRIDGE STREET
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City | CAMBRIDGE
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State | MA
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Zip | 02139
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Country | US
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Telephone | 617-665-1000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 1013861
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License Number State | MA
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