Provider Demographics
NPI:1396026100
Name:INGALLS, LYNN (MSDPT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:INGALLS
Suffix:
Gender:F
Credentials:MSDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6343 E MAIN ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-8954
Mailing Address - Country:US
Mailing Address - Phone:480-325-8838
Mailing Address - Fax:480-325-9191
Practice Address - Street 1:6343 E MAIN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8954
Practice Address - Country:US
Practice Address - Phone:480-325-8838
Practice Address - Fax:480-325-9191
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ62282251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ260534Medicaid