Provider Demographics
NPI:1073889325
Name:LYNCH, THEA (RDN)
Entity Type:Individual
Prefix:MS
First Name:THEA
Middle Name:
Last Name:LYNCH
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:THEA
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED DIETITIAN
Mailing Address - Street 1:3846 N MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1040
Mailing Address - Country:US
Mailing Address - Phone:510-759-4746
Mailing Address - Fax:
Practice Address - Street 1:1601 E 4TH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3713
Practice Address - Country:US
Practice Address - Phone:510-759-4746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10185772133V00000X
CA999481133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered