=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700985413
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYNNE R. MIELKE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4463 STONERIDGE DR STE A
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94588-8402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-846-6300
-----------------------------------------------------
Fax | 925-846-6323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4463 STONERIDGE DR STE A
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94588-8402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-846-6300
-----------------------------------------------------
Fax | 925-846-6323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0005X
-----------------------------------------------------
Taxonomy Name | Neurodevelopmental Disabilities Physician
-----------------------------------------------------
License Number | G59017
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------