Provider Demographics
NPI:1578607933
Name:COOLIDGE, LYNN ANNE (LICENSED PRACTICAL N)
Entity Type:Individual
Prefix:MS
First Name:LYNN ANNE
Middle Name:
Last Name:COOLIDGE
Suffix:
Gender:F
Credentials:LICENSED PRACTICAL N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 ELDER DR
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951-4605
Mailing Address - Country:US
Mailing Address - Phone:631-399-9825
Mailing Address - Fax:
Practice Address - Street 1:129 ELDER DR
Practice Address - Street 2:
Practice Address - City:MASTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11951-4605
Practice Address - Country:US
Practice Address - Phone:631-399-9825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208126-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02069932Medicaid