Provider Demographics
NPI:1063000214
Name:BANNON, LYNDA MARIE (L ATC)
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:MARIE
Last Name:BANNON
Suffix:
Gender:F
Credentials:L ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-2105
Mailing Address - Country:US
Mailing Address - Phone:508-533-9002
Mailing Address - Fax:
Practice Address - Street 1:123 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-3711
Practice Address - Country:US
Practice Address - Phone:781-270-1883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer