Provider Demographics
NPI:1083745608
Name:NICHOLAS, LYNN ANDERSON (PT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:ANDERSON
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:ANDERSON
Other - Last Name:NICHOLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:17 BUCCANEER CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-3255
Mailing Address - Country:US
Mailing Address - Phone:817-236-8181
Mailing Address - Fax:817-236-5154
Practice Address - Street 1:5601 BRIDGE ST
Practice Address - Street 2:SUITE 230
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2384
Practice Address - Country:US
Practice Address - Phone:877-309-9748
Practice Address - Fax:877-309-9749
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1024388174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist