Provider Demographics
NPI:1235657685
Name:LYNCH, MARI-LYN ELLENA (LPN)
Entity Type:Individual
Prefix:
First Name:MARI-LYN
Middle Name:ELLENA
Last Name:LYNCH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 PHOENIX ST
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-2227
Mailing Address - Country:US
Mailing Address - Phone:262-749-2103
Mailing Address - Fax:
Practice Address - Street 1:603 PHOENIX ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-2227
Practice Address - Country:US
Practice Address - Phone:262-749-2103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI321688-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse