Provider Demographics
NPI:1679189153
Name:KIPP, LYNNZIE MARIE
Entity Type:Individual
Prefix:
First Name:LYNNZIE
Middle Name:MARIE
Last Name:KIPP
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 1:5979 VINELAND RD STE 310
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7856
Mailing Address - Country:US
Mailing Address - Phone:407-345-0005
Mailing Address - Fax:407-352-8585
Practice Address - Street 1:5979 VINELAND RD STE 310
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7856
Practice Address - Country:US
Practice Address - Phone:407-345-0005
Practice Address - Fax:407-352-8585
Is Sole Proprietor?:No
Enumeration Date:2020-09-20
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOD347Medicaid
1679189153OtherNPI