Provider Demographics
NPI:1699213033
Name:LYNCH BLACK, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:LYNCH BLACK
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 1:995 JAYMOR RD STE 1
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3855
Mailing Address - Country:US
Mailing Address - Phone:215-605-5289
Mailing Address - Fax:267-722-8249
Practice Address - Street 1:995 JAYMOR RD STE 1
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3855
Practice Address - Country:US
Practice Address - Phone:215-605-5289
Practice Address - Fax:267-722-8249
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN588393163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse