Provider Demographics
NPI:1003182312
Name:LYNCH, SALLY WALLACE (MS, CD-N)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:WALLACE
Last Name:LYNCH
Suffix:
Gender:F
Credentials:MS, CD-N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CRAIGMOOR RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1210
Mailing Address - Country:US
Mailing Address - Phone:860-490-3920
Mailing Address - Fax:
Practice Address - Street 1:11 CRAIGMOOR RD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1210
Practice Address - Country:US
Practice Address - Phone:860-490-3920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000736133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist