MEDICARE: LYNN H SORENSEN RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	ND 4588	FL

General Provider Information

NPI Number	:	1053519496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNN H SORENSEN RD, LD

Provider Business Mailing Address
First Line	:	1016 SEA HAWK DR
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-1646
Country	:	US
Telephone Number	:	904-608-9133
Fax Number	:

Provider Business Practice Location Address
First Line	:	1545 LANDON AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8671
Country	:	US
Telephone Number	:	904-737-3232
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2007
Last Update Date	:	07/08/2007

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