Provider Demographics
NPI:1649211210
Name:FASANELLO, LYNNE A (MD)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:A
Last Name:FASANELLO
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 1:2007 BAY ST.
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780
Mailing Address - Country:US
Mailing Address - Phone:508-880-7858
Mailing Address - Fax:508-822-7952
Practice Address - Street 1:2007 BAY ST.
Practice Address - Street 2:SUITE 103
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780
Practice Address - Country:US
Practice Address - Phone:508-880-7858
Practice Address - Fax:508-822-7952
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3197026Medicaid
MAG96564Medicare UPIN
MAA29750Medicare ID - Type Unspecified