Provider Demographics
NPI:1225704711
Name:WIDELO, LYNNESSA ROBYN (NP)
Entity Type:Individual
Prefix:
First Name:LYNNESSA
Middle Name:ROBYN
Last Name:WIDELO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2282 REED CREEK DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:VA
Mailing Address - Zip Code:24324-2858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:280 N POINTE BLVD STE 3
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2267
Practice Address - Country:US
Practice Address - Phone:336-948-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182343363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health