Provider Demographics
NPI:1548210230
Name:LYNESS, JUDITH C (NP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:C
Last Name:LYNESS
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 1:205 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1642
Mailing Address - Country:US
Mailing Address - Phone:608-375-4112
Mailing Address - Fax:
Practice Address - Street 1:200 W BLUFF ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1601
Practice Address - Country:US
Practice Address - Phone:608-375-2424
Practice Address - Fax:608-375-6285
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1166033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43877300Medicaid
WI43877300Medicaid