Provider Demographics
NPI:1689947467
Name:NIDEK, LYNNE M (MS PT)
Entity Type:Individual
Prefix:MRS
First Name:LYNNE
Middle Name:M
Last Name:NIDEK
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 KILBURN RD
Mailing Address - Street 2:
Mailing Address - City:BERKEY
Mailing Address - State:OH
Mailing Address - Zip Code:43504-9731
Mailing Address - Country:US
Mailing Address - Phone:419-787-3120
Mailing Address - Fax:
Practice Address - Street 1:100 POWELL DR
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:MI
Practice Address - Zip Code:48131-8644
Practice Address - Country:US
Practice Address - Phone:419-276-2976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015682225100000X
OHPT 009632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist