Provider Demographics
NPI:1073830899
Name:FONTANA, LYNN MARIE
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:MARIE
Last Name:FONTANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70411 DESERT COVE AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-2918
Mailing Address - Country:US
Mailing Address - Phone:760-668-6364
Mailing Address - Fax:
Practice Address - Street 1:255 N EL CIELO RD # C326
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-6992
Practice Address - Country:US
Practice Address - Phone:760-668-6364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA341836390200000X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program