Provider Demographics
NPI:1265486443
Name:MCNICOLL, LYNN (MD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:MCNICOLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 VIRGINIA AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4406
Mailing Address - Country:US
Mailing Address - Phone:401-443-4992
Mailing Address - Fax:401-784-4902
Practice Address - Street 1:375 WAMPANOAG TRL
Practice Address - Street 2:SUITE 102
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2212
Practice Address - Country:US
Practice Address - Phone:401-649-4010
Practice Address - Fax:401-649-4011
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10775207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9026358Medicaid
RI007056278Medicare PIN