Provider Demographics
NPI:1194843334
Name:BURKE, LYNN C ATHERINE (RPT,MS,CCI)
Entity Type:Individual
Prefix:MS
First Name:LYNN
Middle Name:C ATHERINE
Last Name:BURKE
Suffix:
Gender:F
Credentials:RPT,MS,CCI
Other - Prefix:MRS
Other - First Name:LYNN
Other - Middle Name:C
Other - Last Name:STASIOWSKI-BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT,MS,CCI
Mailing Address - Street 1:43 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5122
Mailing Address - Country:US
Mailing Address - Phone:860-647-1939
Mailing Address - Fax:
Practice Address - Street 1:100 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-4252
Practice Address - Country:US
Practice Address - Phone:860-714-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005866174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT005866Medicare UPIN