Provider Demographics
NPI:1679665020
Name:ALONSO, LYNESSA A (DO)
Entity Type:Individual
Prefix:
First Name:LYNESSA
Middle Name:A
Last Name:ALONSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SAINT CLARE CT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9239
Mailing Address - Country:US
Mailing Address - Phone:309-886-4003
Mailing Address - Fax:
Practice Address - Street 1:10 SAINT CLARE CT
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-9239
Practice Address - Country:US
Practice Address - Phone:309-886-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111658207RA0000X
IL036111658208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00736603OtherRAILROAD MEDICARE
IL036111658Medicaid
000000597576OtherNCMA/ANTHEM
KY7100079490Medicaid
000023044ZOtherNCMA/HUM
101430OtherNCMA/SIHO
P00736603OtherRAILROAD MEDICARE
KY00533102Medicare PIN