Provider Demographics
NPI:1528597655
Name:DELLA GROTTA, LYNN
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:DELLA GROTTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 METRO CENTER BLVD STE 2000
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1785
Mailing Address - Country:US
Mailing Address - Phone:401-432-2500
Mailing Address - Fax:401-889-3619
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-432-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2915942085R0202X
390200000X
RIMD194312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program